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in the
Promotion of
Health and Wellness
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in the
Promotion of
Health and Wellness
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Department of Occupational Therapy
University of South Alabama
Mobile, AL

S. Maggie Reitz, PhD, OTR/L, FAOTA

Professor and Chair
Department of Occupational Therapy and Occupational Science
Towson University
Towson, MD

Michael A. Pizzi, PhD, OTR/L, FAOTA

Touching Humanity, Inc.
Wellness Consultant
New York City, NY
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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103

Copyright 2010 by F. A. Davis Company

Copyright 2010 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be repro-
duced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording,
or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher: Margaret Biblis

Senior Acquisitions Editor: Christa Fratantoro
Manager of Content Development: George W. Lang
Developmental Editor: Peg Waltner
Art and Design Manager: Carolyn OBrien
Cover image: Courtesy of Brand X Pictures

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies
undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord
with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions
or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the
book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used
in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information
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is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Scaffa, Marjorie E.
Occupational therapy in the promotion of health and wellness / Marjorie E. Scaffa, S. Maggie Reitz, Michael A. Pizzi.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1193-1
ISBN-10: 0-8036-1193-5
1. Health promotion. 2. Occupational therapy. I. Reitz, S. Maggie. II. Pizzi, Michael, III. Title.
[DNLM: 1. Occupational Therapy. 2. Health Behavior. 3. Health Promotion. WB 555 S278o 2010]
RA427.8.S23 2010

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A.
Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that
the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been
granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional
Reporting Service is: / + $.10.
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In our own daily occupations, we have many people who teach us about life, health,
wellbeing, and what it is to be a productive member of society. This book is dedicated
to those who have taught us, and continue to teach us, to believe in the limitless power
of occupational engagement to promote health and wellbeing and prevent and reduce
disability. It is our fervent hope that this book will inspire and instruct us all to live
full, productive, and healthy lives.

Marjorie dedicates this book to the memory of her mother, Doris R. Scaffa, and grand-
mother, Marjorie M. Scaffa, who lived lives of love, laughter, and commitment, and
inspired her to do the same.

Maggie dedicates this book to her parents, Mr. William Ross & Mrs. Patricia
Thomson; sister, Heather L. Gratton; daughter, Jessica L. Reitz; and last but not
least, her life partner Fred, for their efforts to facilitate her development as an in-
dividual committed to social and occupational justice.

Michael dedicates this book to the memory of his parents, who, despite chronic illness
and disenfranchisement, taught him the lesson of being fully human and fully alive
and to face lifes obstacles with great compassion, understanding, and dignity. Michael
also dedicates this book to his partner and legal spouse, Kenneth Brickman, who
provides a nurturing, loving, and supportive environment in which he can create.

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The three of us have known each other for over 20 years, first as practitioners and then
as educators. In 2002, over dinner during the American Occupational Therapy Asso-
ciation conference, Michael suggested that the foundation for wellness and health
promotion in occupational therapy was finally solidifying but that there were no sig-
nificant occupational therapy textbooks specifically committed to the subject. Thus, a
project that held great importance to the three of us was born!
We, the editors and chapter authors, share a strong commitment, passion, and ur-
gency to further the profession and strengthen the groundwork that was laid decades
ago but was never properly acknowledged or fully developed. Wilma West, Geraldine
Finn, and Ruth Brunyate Wiemer are three of the prominent pioneers on whose shoul-
ders we stand.

In order for a profession to maintain its relevancy it must be responsive

to the trends of the times. The trend today in health services is toward the
prevention of disability. Occupational therapists are being asked to move
beyond the role of the therapist to that of health agent. This expansion
in role identity will require a reinterpretation of current knowledge, the
addition of new knowledge and skills, and the revision of the educational

Finn made that prophetic statement in 1972. What happened? An attachment to medical-
izing what we do transformed our profession for decades. Health care has undergone
major shifts and continues to dramatically change. It is time to reclaim our rightful place
in prevention of disability and the promotion of health and healthy lifestyles. As a profes-
sion, we risk losing an opportunity to be world leaders as the health agents about which
Finn spoke so eloquently. The shift to health agent takes little effortit does, however,
take tremendous dedication, passion, and commitment to the values of occupational ther-
apy and to the power of occupation in daily life. Wellness and health promotion, com-
bined with occupation, can expand the scope and impact of occupational therapy in the
We are grateful for this opportunity to share our vision for the future of occupa-
tional therapy. We welcome our colleagues, students, and friends to share their own
visions of wellbeing, health promotion, and prevention; to build bridges between those
visions and current practice; and to create new and insightful strategies that support
productivity and wellbeing for individuals, families, communities, and society.
Together we can become leading health agents of the 21st century!

Marjorie E. Scaffa, PhD, OTR/L, FAOTA

S. Maggie Reitz, PhD, OTR/L, FAOTA
Michael A. Pizzi, PhD, OTR/L, FAOTA

Finn, G. (1972). The occupational therapist in prevention programs.
American Journal of Occupational Therapy, 26(2), 5966.

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Melba J. Arnold, MS, OTR/L Georgiana Herzberg, PhD, OTR/L
Assistant Professor Retired
Department of Occupational Science and Previously of Nova Southeastern
Occupational Therapy University
Saint Louis University Jacksonville, FL
St. Louis, MO
Marie F. Kuczmarski, PhD, RD, LDN
Angela Blair-Newton, OTR Professor of Nutrition
Occupational Therapist Department of Health, Nutrition and
Tyler, TX Exercise Sciences
Bette R. Bonder, PhD, OTR/L, FAOTA University of Delaware
Dean and Professor Newark, DE
College of Science Kathleen Matuska, MPH, OTR/L
Cleveland State University Associate Professor and Director
Cleveland, OH MAOT Program
Kimberly Mansfield Caldeira, MS St. Catherine University
Faculty Research Associate St. Paul, MN
Center for Substance Abuse Research M. Beth Merryman, PhD, OTR/L
University of Maryland Associate Professor
College Park, MD Department of Occupational Therapy and
Regina Michael Campbell, MS, OTR, FAOTA Occupational Science
Associate Professor Towson University
School of Occupational Therapy Towson, MD
Texas Womans University Penelope Moyers, EdD, OTR, FAOTA
Dallas, TX Professor and Chair
Charles H. Christiansen, EdD, OTR, FAOTA Department of Occupational Therapy
Executive Director University of Alabama at Birmingham
American Occupational Therapy Birmingham, AL
Foundation Lynne Murphy, MS, OT/L
Bethesda, MD Clinical Assistant Professor
S. Blaise Chromiak, MD Department of Occupational Therapy and
Family Physician Occupational Science
Mobile, AL Towson University
Towson, MD
Karen Goldrich Eskow, PhD
Professor and Chairperson Theresa M. Petrenchik, PhD, OTR/L
Department of Family Studies and Assistant Professor
Community Development Occupational Therapy Graduate Program
Towson University University of New Mexico
Towson, MD Albuquerque, NM

Linda Fazio, PhD, OTR/L, FAOTA

Professor of Clinical Occupational
University of Southern California
Los Angeles, CA

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x Contributors

Rebecca Renwick, PhD, OT Reg (Ont) Theresa M. Smith, PhD, OTR, CLVT
Professor, Department of Occupational Assistant Professor
Science and Occupational Therapy School of Occupational Therapy
Graduate Department of Rehabilitation Texas Womans University
Science Houston, TX
Director, Quality of Life Research Unit
University of Toronto Virginia C. Stoffel, PhD, OT, BCMH, FAOTA
Toronto, Ontario, Canada Associate Professor and Chair
Occupational Therapy Department
Patricia Atwell Rhynders, PhD, MPH, CHES University of Wisconsin
Associate Professor Milwaukee, WI
Colleges of Health Science and
Education C. Barrett Wallis, OTR
TUI University Occupational Therapist
Cypress, CA Mobile, AL

Marlene Riley, MMS, OTR/L, CHT Ann A. Wilcock, PhD, GradDip Public
Clinical Associate Professor Health, BAppScOT, DipOT
Department of Occupational Therapy Honorary Professor
and Occupational Science Occupational Science and Occupational
Towson University Therapy
Towson, MD Deakin University
Geelong, Australia
Debra Rybski, MS, MSHCA, OTR/L
Assistant Professor
Department of Occupational Science and
Occupational Therapy
Saint Louis University
St. Louis, MO
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Karen Ann V. Cameron, OTD, MEd, OTR/L Ferol Menks Ludwig, PhD, OTR, FAOTA, GCG
Program Director and Assistant Professor Emeritus
Professor Occupational Therapy Department
Occupational Therapy Department Nova Southeastern University
Alvernia College Ft. Lauderdale, FL
Reading, PA
Patricia E. Marvin, OTD, OTR/L
Elizabeth Ciaravino, PhD, OTR/L Assistant Professor
Assistant Professor Occupational Therapy Department
Occupational Therapy Department University of St. Augustine for Health
The University of Scranton Professions
Scranton, PA St. Augustine, FL
Helen Z. Cornely, PT, MS Gail F. Metzger, BS, MS, OTR/L
Associate Professor of Physical Therapy Assistant Professor
Florida International University Occupational Therapy Department
Miami, FL Alvernia College
Reading, PA
Janis Davis, PhD
Assistant Professor Maralynne D. Mitcham, PhD, OTR/L, FAOTA
Occupational Therapy Department Professor and Director
Rockhurst University Occupational Therapy Educational
Kansas City, MO Program
Department of Rehabilitation Sciences
Joanne Gallagher, EdD, OTR/L College of Health Professions
Chair and Associate Professor
Medical University of South Carolina
Occupational Therapy Department
Charleston, SC
Worcester State College
Worcester, MA Karin J. Opacich, PhD, MHPE, OTR/L, FAOTA
EXPORT Project Director and Assistant
Lynn Gitlow, PhD, OTR/L Director
Director of Occupational Therapy
National Center for Rural Health
Husson College
Bangor, ME
University of Illinois Rockford
Liane Hewitt, DrPH (cand), OTR/L Rockford, IL
Assistant Professor
Betsey C. Smith, PhD, OTR/L
Occupational Therapy Department
Occupational Therapy Program Director
Loma Linda University
University of Hartford
Loma Linda, CA
West Hartford, CT
Angela N. Hissong, DEd, OTR/L Jill Smith, MS, OTR/L
Occupational Therapy Program
Assistant Professor of Occupational
The Pennsylvania State University
Milligan College
Mont Alto, PA
Milligan College, TN
Kathleen Marie Kniepmann, MPH, EdM, CHES, Janet H. Watts, PhD, OTR
OTR/L Retired Associate Professor
Virginia Commonwealth University
Occupational Therapy Program
Department of Occupational Therapy
Washington University in St. Louis
Richmond, VA
St. Louis, MO
Quality Assurance and Training
Chamberlin Edmonds Company
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Although it is impossible to list every person who impacted the development and cre-
ation of this book and the ideas contained therein, we would like to acknowledge sev-
eral people without whose time and talent this book would not have come to fruition.
Among these are the excellent staff at F. A. Davis, specifically Christa Fratantoro, our
Senior Acquisitions Editor and coach extraordinaire; Margaret M. Biblis, the Pub-
lisher for Health Professions and Medicine, who believed in the potential impact
of this text before a single word was written; and Peg Waltner, our Developmental
Editor, for her tireless and invaluable assistance throughout the editorial process.
We would also like to thank our visionary colleagues and contributors who shared
our excitement regarding the significant role of occupational therapy in prevention and
health promotion. We have learned a great deal from reading their work, and we hope
you do as well.
In addition, we wish to express our gratitude to S. Blaise Chromiak and Fred Reitz
for their emotional support and the countless hours they spent reviewing and editing
the chapters, and to Grace Wenger for her assistance in acquiring the permissions
needed for some of the figures and tables in the text. We are also grateful to the
reviewers, whose helpful feedback was used to improve the content and organization
of the book.
On a personal note, Maggie expresses her thanks to her family, Fred and Jess
Reitz, for their tolerance during the lengthy birthing process of this book. Missed fam-
ily occupational opportunities were only a part of the sacrifices they made to allow this
book to come to fruition. In addition, Maggie thanks her colleagues at Towson
University for their patience, and she owes a special thank-you to the following peo-
ple who supported this enterprise while they were occupational therapy students at
Towson University: Alex Stroup, Beth Frey, Cheryl Merritt, Gar-Wing Tsang, Grace
Wenger, Sarah Biederman, and Audrey Grant.
Finally, we would like to thank our patients and clients, who have taught us so
much about the power of occupation, and we thank the many students who, over the
years, asked important questions and challenged us to discover and develop new
explanations. We hope this book fulfills a need for occupational therapy faculty, stu-
dents, and practitioners and ultimately improves the quality of care for the recipients
of occupational therapy services.

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SECTION I: Foundations and Key Concepts Chapter 3 Health Behavior Frameworks for Health
Promotion Practice 46
Chapter 1 Historical and Philosophical Perspectives S. Maggie Reitz, PhD, OTR/L, FAOTA
of Occupation Therapys Role in Health Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Promotion 1
Regina Michael Campbell MS, OTR, FAOTA
S. Maggie Reitz, PhD, OTR/L, FAOTA
Patricia Atwell Rhynders, PhD, MPH, CHES
Introduction 1
Introduction 47
Historical and Cultural Views of Health
Health Behavior Theories: An Overview 47
and Healing 1
Diffusion of Innovations: An Overview 49
Historical Use of Occupation to Heal
and Promote Wellbeing 3 Health Belief Model: An Overview 53
Select Historical Milestones in Health PRECEDE-PROCEED Model:
Promotion and Prevention Within An Overview 58
Occupational Therapy in the Social Ecological Model of Health:
United States 5 An Overview 60
Official Documents and Activities of Transtheoretical Model: An Overview 62
AOTA Related to Health Promotion Chaos Theory: A Brief Overview 64
and Prevention 11
Selecting and Matching Theories 65
Conclusion 15
Conclusion 65
Chapter 2 Occupational Therapy Conceptual Models
Chapter 4 Public Health Principles, Approaches,
for Health Promotion Practice 22
and Initiatives 70
S. Maggie Reitz, PhD, OTR/L, FAOTA
S. Maggie Reitz, PhD, OTR/L, FAOTA
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Michael A. Pizzi, PhD, OTR/L, FAOTA
Introduction 70
Introduction 22
History of Public Health in the
Importance of Theory to Health United States 71
Promotion Practice 23
Terminology and the Role of
Terminology and Relationships Between Occupational Therapy in the New
Philosophy, Theory, Practice, Public Health 73
and Research 24
International Official Health Promotion
Occupational Therapy Theories/Models 26 Documents and Initiatives 75
Occupational Adaptation (OA): U.S. Governmental Documents on
Overview 32 Health Promotion 78
Person-Environment-Occupation (PEO): U.S. Government and Professional
Overview 35 Association Public Health Initiatives 87
Person-Environment-Occupation- Conclusion 91
Performance Model (PEOP): Overview 38
Recent Advancements and Potentially Chapter 5 Cultural and Sociological Considerations
New Models 41 in Health Promotion 96
Conclusion 42 Bette Bonder, PhD, OTR/L, FAOTA
Introduction 96
Defining Terms 97
Spirituality, Religion, and Health 99
Cultural Competency 101
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xvi Contents

The Importance of Culture and An International Perspective 141

Socioeconomic Status in Health Vulnerable Populations 141
and Health Care 101
Occupational Justice and Injustice 143
Cultural and Socioeconomic Factors
Agents That Impose Occupational
and Occupation 102
Injustice and Targets Who Are
Culture and Occupation 103 Predisposed to Occupational Injustice 144
Occupational Therapy in the Promotion Occupational Injustice at Individual,
of Health and Wellness: Cultural Community, National, and International
and Socioeconomic Considerations 105 Levels 144
Conclusion 106 Occupational Justice in the Promotion
of Health and Wellbeing 148
Chapter 6 Population Health: An Occupational
Occupational Justice and the
Rationale 110
Occupational Therapy Process
Ann A. Wilcock PhD, GradDip, Public Health, in Health Promotion 148
Conclusion 151
Introduction 110
An Occupational Perspective SECTION II: Designing Health Promotion
of Population Health 110
The Relationship Between Health
and Occupation 112 Chapter 9 Evaluation Principles in Health
Underlying Occupational Determinants Promotion Practice 157
of Health 114 S. Maggie Reitz, PhD, OTR/L, FAOTA
Occupational Science and Population Michael A. Pizzi, PhD, OTR/L, FAOTA
Health: Occupational Therapy
Framework 115 Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Conclusion 119 Introduction 158
Best Practice and Evidence-Based
Chapter 7 Quality of Life and Health Promotion 122 Practice in Health Promotion
Michael A. Pizzi, PhD, OTR/L, FAOTA Assessment 158
Rebecca Renwick, PhD, OT Reg (Ont) The Language, Evolution, and
Philosophical Aspects of Health
Introduction 122
Promotion Assessment 160
Occupation and Quality of Life 124
The Framework and the ICF 161
Quality of Life and Health Promotion 124
Issues in Assessment 164
Influential Perspectives on Quality
Assessment Selection 168
of Life 124
Component Versus Holistic Assessment
Quality of Life Across the Life Span 125
and Objective Versus Subjective
Conclusion 131 Assessment 169
Conclusion 170
Chapter 8 Occupational Justice 135
Melba J. Arnold, MS, OTR/L Chapter 10 Assessments for Health Promotion
Debra Rybski, MS, MSHCA, OTR/L Practice 173
Introduction 135 Michael A. Pizzi, PhD, OTR/L, FAOTA
Social Justice 136 S. Maggie Reitz, PhD, OTR/L, FAOTA
Social Injustice 137 Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Social Identity and Oppression 138 Introduction 173
Socioeconomical and Political Issues 140 Occupational Therapy Assessments 173
Health Disparities 140
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Contents xvii

Wellness and Health PromotionSpecific SECTION III: Occupational Therapys

Assessments 181
Contributions to Health
Quality-of-Life Assessments 185
Behavior Interventions
Community Assessment 187
Conclusion 190 Chapter 13 Promoting Exercise and Physical
Activity 225
Chapter 11 Health Promotion Program
S. Maggie Reitz, PhD, OTR/L, FAOTA
Development 195
Introduction 225
Linda S. Fazio, PhD, OTR/L, FAOTA
Historical Trends 226
Introduction 195
Terminology 227
Developing the Idea for Programming 196
U.S. National Health Objectives
Assessing the Need for Services 197
Related to Physical Activity 229
Developing Community Profiles 199
Prevalence Rates 232
Developing Community Programming
Barriers to Physical Activity
Goals, Objectives, and Activities 199
Engagement 234
Use of Theory to Guide Programming 201
Health Benefits of Physical Activity
Searching for Evidence That and the Health Risks of Physical
Programming Will Be Effective 202 Inactivity 236
Evidence for the Potential Effectiveness Governmental and National
of the Program: Program Evaluation 203 Organizations and Documents
Case Examples of Program That Promote Physical Activity 237
Development and Evaluation 205 Theoretical Models and Research 239
Conclusion 206 Assessment Measures 241
Occupational Therapys Role in
Chapter 12 Enhancing Community Health Through
Promoting Physical Activity 242
Community Partnerships 208
Conclusion 247
Patricia Atwell Rhynders, PhD, MPH, CHES
Marjorie E. Scaffa, PhD, OTR/L, FAOTA Chapter 14 Weight Management and Obesity
Introduction 208 Reduction 253
Community Health 209 Marie Kuczmarski PhD, RD, LDN
Population Health Strategies 211 S. Maggie Reitz, PhD, OTR/L, FAOTA
Community Health Interventions 212 Michael A. Pizzi, PhD, OTR/L, FAOTA
Principles of Community Health Introduction 253
Intervention 212 Weight Regulation 254
Collaboration, Partnerships, and Prevalence of Overweight and Obesity 255
Coalition-Building 213
Health Risks 256
Community Health and Occupational
Weight Bias 258
Therapy 216
Economic Burden of Obesity 258
Promoting Community Health 218
Healthy Lifestyle Behaviors: Dietary
Opportunities and Challenges 219
and Physical Activity
Examples of Community Health Recommendations 259
Initiatives 220
Weight Management 260
Evaluation of Community Health
Guidelines for Treatment of
Interventions 221
Overweight and Obesity
Conclusion 222 in Children 261
Guidelines for Obesity Prevention
for Youth 261
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xviii Contents

Guidelines for Treatment of Overweight Sexually Transmitted Infections (STIs)

and Obesity in Adults 264 and Sexually Transmitted
Weight-Reduction Strategies 264 Diseases (STDs) 316
Considerations for All Health Human Immunodeficiency Virus (HIV) 318
and Fitness Professionals 268 Occupational Therapy
Role of Registered Dietitians and and Sexual Health 319
Others in Weight Management and Sexual Health Interventions 321
Obesity Prevention 268 Conclusion 324
Role of Occupational Therapy in
Weight Management and Obesity Chapter 17 Promoting Mental Health
Prevention 269 and Emotional Wellbeing 329
Role of Interdisciplinary Interventions Marjorie E. Scaffa, PhD, OTR/L, FAOTA
in Weight Management and Obesity Michael A. Pizzi, PhD, OTR/L, FAOTA
Prevention 272
S. Blaise Chromiak, MD
Conclusion 273
Introduction 329
Chapter 15 Preventing Substance Abuse Definitions of Mental Health 330
in Adolescents and Adults 280 Positive Psychology 331
Penelope Moyers, EdD, OTR, FAOTA Characteristics of Mentally
Virginia C. Stoffel, PhD, OTR, BCMH, FAOTA Healthy People 333
Introduction 280 Assessing Mental Health 334
Prevalence of Substance-Use Disorders 281 Mental Health Promotion 335
Prevention Approaches 281 Strategies for Promoting Mental Health 338
The Occupational Perspective on Resilience 338
Substance Abuse Prevention 282 Conclusion 346
Evidence-Based Prevention Programs 285
Chapter 18 Unintentional Injury and Violence
Role of Occupational Therapy 299
Prevention 350
Conclusion 303
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Chapter 16 Promoting Sexual Health: An Occupational S. Blaise Chromiak, MD
Perspective 307 S. Maggie Reitz, PhD, OTR/L, FAOTA
Michael A. Pizzi, PhD, OTR/L, FAOTA Angela Blair-Newton, OTR/L
S. Maggie Reitz, PhD, OTR/L, FAOTA Lynne Murphy, MS, OT/L
Introduction 307 C. Barrett Wallis, OTR/L
Definitions of Sexuality Terminology 308 Introduction 350
Sexual Health 308 A Public Health Perspective 352
A Developmental Perspective Unintentional Injury 352
on Sexual Health: Children and Injuries Due to Violence 359
Adolescents 310
Mental Health Aspects of Unintentional
Sexual Health Promotion and Youth 311 Injury and Violence 368
A Developmental Perspective on Principles of Unintentional Injury
Sexual Health: Adults 312 and Violence Prevention 369
A Developmental Perspective on Role of Occupational Therapy
Sexual Health: Older Adults 314 in Unintentional Injury
Sexual Health Promotion and Violence Prevention 370
and Older Adults 315 Conclusion 371
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Contents xix

SECTION IV: Health Promotion Dynamics of Family Life 417

and Prevention From an Families and Community Life 422
Occupational Therapy Impact of Physical Disability on
the Health of a Family 424
Impact of Mental and Substance Abuse
Chapter 19 Health Promotion for People Disorders on the Health of a Family 424
With Disabilities 376 Influence of Health-Care Practitioners
Michael A. Pizzi, PhD, OTR/L, FAOTA on the Familys Adaptation 426
Introduction 376 Conclusion 428
Justice for Individuals With Chapter 22 Health Promotion for Individuals
Disabilities 378 and Families Who Are Homeless 434
Models for Health Promotion 380 Georgiana Herzberg, PhD, OTR
Research in Health Promotion Theresa M. Petrenchik, PhD, OTR/L
and People With Disabilities 383
Introduction 434
Occupational Perspective on Health
Promotion and Disability 386 Homelessness: Definition, Context,
and Characteristics 435
Health Promotion for Children
and Youth With Disabilities 388 Occupational Therapy Roles 438
Evaluation and Assessment 389 Partnership Building 440
Health Promotion and Occupational Needs Assessment 443
Interventions 390 Sample Occupational Therapy
Conclusion 392 Interventions 446
Conclusion 449
Chapter 20 Promoting Health and Occupational
Participation With Caregivers 397 Chapter 23 Promoting Successful Aging Through
Michael A. Pizzi, PhD, OTR/L, FAOTA Occupation 454
Introduction 397 Michael A. Pizzi, PhD, OTR/L, FAOTA
Conceptual Frameworks for Caregiving 398 Theresa M. Smith, PhD, OTR, CLVT
The Family Life Cycle 399 Introduction 454
Caregiver Health 399 Successful Aging 455
Challenges of Caregiving 400 Aging and Successful Aging Theories 456
Health Promotion and Wellbeing Health Risks and Behaviors in Aging 458
Issues for the Caregiver 404 Factors Inhibiting Access to
Evaluation and Assessment and Participation in Occupation 459
of Caregivers 406 Current State of Practice
Interventions for Caregivers 407 in Occupational Therapy 460
Conclusion 409 Health Promotion and Participation 461
Health Promotion Program Examples 461
Chapter 21 Health Promotion for Families 415 Health Literacy 465
Karen Goldrich Eskow, PhD Conclusion 465
M. Beth Merryman, PhD, OTR/L
Introduction 415
Family-Centered Care
in Occupational Therapy 416
Defining the Family 416
Family Life Cycle 417
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xx Contents

Chapter 24 Preventing Falls Among Marlene Riley, MMS, OTR/L, CHT

Community-Dwelling Older Adults 470 M. Beth Merryman, PhD, OTR/L
Kimberly Mansfield Caldeira, MS Marjorie E. Scaffa, PhD, OTR/L, FAOTA
S. Maggie Reitz, PhD, OTR/L, FAOTA Introduction 512
Introduction 470 Service Learning 513
Background of the Problem 471 Infusing Health Promotion and
Risk Factor Research 475 Wellness Into Occupational Therapy
Education 514
Guidelines for Evidence-Based
Evaluation 480 Conclusion 525
Guidelines for Evidence-Based
Chapter 27 Health Promotion Research
Interventions 480
in Occupational Therapy 528
The Occupational Therapy Practitioners
Charles H. Christiansen, EdD, OTR, FAOTA
Role in Fall Prevention 486
Kathleen M. Matuska, MPH, OTR/L
Conclusion 488
Introduction 528
Chapter 25 Promoting Wellness The Need for Health Promotion
in End-of-Life Care 493 Research 529
Michael A. Pizzi, PhD, OTR/L, FAOTA The Special Challenge of Health
Introduction 493 Promotion Research 530
History of Occupational Therapy Ideas That Influence Health
in ELC 494 Promotion Research 531
Definitions and Meanings in ELC 495 Types of Research in Health
Promotion 531
Client-Centered Care and Therapeutic
Use of Self in ELC 497 Participatory Research 533
ELC and Health Promotion: Health Promotion Research
A Natural Fit 498 in Occupational Therapy 534
Contexts for ELC and Palliative Care 500 Barriers and Challenges
in Health Promotion Research 536
Interventions Across Contexts 503
Conclusion 537
Occupational Therapy Research
in ELC 503
Appendix A Selection of Key Historical Highlights
Occupational Therapy Evaluation 504 in Public Health 541
Occupational Interventions to Promote Appendix B Summary of Recommendations of
a Good Death 506
Institute of Medicine (IOM) Report 544
Conclusion 507
Appendix C Dietary Guidelines for Americans, 2005
SECTION V: Implications for Occupational
Appendix D Recommended Computer Workstation
Therapy Education and Guidelines 547
Appendix E Family Self-Analysis 548
Chapter 26 Educating Practitioners for Health Appendix F Parent Tips for Child Success 549
Promotion Practice 512 Appendix G Falls Prevention Assessment
Regina Michael Campbell, MS, OTR, FAOTA Checklist 551
Patricia Atwell Rhynders, PhD, MPH, CHES Index 553
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SECTION I Foundations and Key Concepts

Chapter 1

Historical and Philosophical Perspectives

of Occupational Therapys Role in Health
S. Maggie Reitz

In 1991, occupational therapy was identified as the only health profession that had fully
embraced the concepts of: health promotion and prevention, community-based care and the
individual as centre to the process
by Steven Lewis, former leader of the national New Democratic Party in Canada as part of his
remarks as the keynote speaker at the 1991 Canadian Association of Occupational Therapist
(CAOT) Conference (as cited by Green, Lertvilai, & Bribrieso 2001, 2).

Learning Objectives
This chapter is designed to enable the reader to:
Articulate humans evolutionary, cross-cultural Describe the historical roots, documents, and
use of occupations to promote healing and literature of occupational therapys role in health
prevent disease and disability. promotion and their potential use to support
Discuss the historical development of occupa- and enhance current health promotion inter-
tional therapy as a caring health profession that ventions and innovative evidenced-based health
has emphasized prevention, health promotion, promotion practice.
and wellbeing since its inception.

K e y Te r m s
Client Moral treatment Shell shock
Disability prevention Prevention Wellness
Health promotion

Introduction perspective will enable the reader to link current

practice with philosophical tenets and historical
After a brief review of early historical views on heal- interventions and policies to establish a foundation
ing, health, and the use of occupations, this chapter for todays health promotion interventions.
traces the professions roots in the philosophy and
delivery of preventive and health promotion services.
Official documents and activities within the American Historical and Cultural Views
Occupational Therapy Association (AOTA) related to
health promotion and prevention will be presented.
of Health and Healing
This review focuses on health-promotion activities Many cultures around the world have developed similar
within the United States as influenced by both beliefs regarding health, wellbeing, and occupational
domestic and international activities. This historical engagement. While historical reviews often focus on
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2 SECTION I Foundations and Key Concepts

Greek and Roman contributions, other civilizations

have contributed to the development and evolution of
the medical and healing arts. Travel and exploration, as
well as war, have facilitated the sharing of this knowl-
edge between cultures. Ancient beliefs have influenced
health-care practices through the years and continue to
inform current developments. Tai chi is an excellent
example of this type of continued impact. Being knowl-
edgeable about healing and health beliefs that span time
and cultures is important as the profession of occupa-
tional therapy seeks to provide culturally competent
care. The following brief review provides a glimpse into
humans rich history of engaging in healing and health-
promotion occupations.
Greek mythology provides an early view of the Greeks
beliefs regarding health and healing. Asclepius, the son of
Apollo, was the god of medicine (Anderson, Anderson, &
Glanze, 1998). According to mythology, Asclepius was the
father of Panacea, the goddess of healing, and Hygeia, the
goddess of health (Lasker & The Committee on Medicine
and Public Health 1997). Hygeia is depicted with her
father in Figure 1-1. It is now believed the myth of Aescu-
lapius may have arisen as a result of the efforts of one
or more individuals with exceptional healing abilities.
Humans attributed divine status to those abilities and
the legendary Aesculapius was then worshipped through-
out the ancient Mediterranean area (National Library of
Medicine [NLM], 2004a).
Throughout human history, healers have been
afforded a special place in society. However, in some
societies those who practiced medicine were more Figure 1-1 Asclepius and Hygeia in allegorical setting.
highly respected than those interested in prevention and
Courtesy of the National Library of Medicine.
health promotion. This division between health promo-
tion and healing and the overshadowing of prevention
and maintenance by medicine was described by Plato
The dichotomy between healing and prevention
(Friedland, 1998, p. 374):
does not appear in early writings from Persia, China,
In the . . . therapeutic arts, the corrective portion is and India. According to early Islamic writings:
more apparent but less important, while the regulative
Medicine is a science from which one learns the states of
portion is largely hidden, but far more essential. . . .
the human body with respect to what is healthy and what
[Hence] there is grave danger lest prevention and
is not, in order to preserve good health when it exists and
maintenance, the real work of the art, be overlooked,
restore it when it is lacking. (Ibn Sina, the opening to the
and attention exclusively be devoted to the correction
Qanun fi al-tibb, cited by Savage-Smith, 1994)
of the diseases already there.
In the famous Chinese medical text Nei Chang
While this division was aptly described by Plato
(Canon of Medicine), which dates back to 2600 BC, the
in his world, a slightly different view was held by
Yellow Emperor, Yu Hsiung, describes both prevention
the indigenous people of the Americas. They had an
and treatment (Lyons & Petrucelli, 1987). The impor-
appreciation of the link between rubbish and illness
tance of balance and the connection of humans to
and believed prevention was of great value. The
the physical and spiritual world were at the center of
medicine of the South American Indian primarily
Chinese healing and prevention activities in the last
focused on hygiene, as such medicine ought to be,
three centuries B.C. (Sivin, 1995, p. 5):
it being of greater daily importance to preserve
health than to cure disease (Spruce as cited by Since ancient times [it has been understood that] pen-
Vogel, 1970, p. 261). etration by [the chi of] heaven is the basis of life,
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 3

which depends on [the universal chi of] yin and yang. This historical review of examples supports the con-
The chi [of everything] in the midst of heaven and tinued development and evolution of health promotion
earth and in the six directions, from the nine provinces as well as the need to study the effectiveness of blend-
and nine body orifices to the five visceral systems and ing preventive care with medical and rehabilitative
the twelve joints, is penetrated by the chi of heaven. approaches. Knowledge of history also helps practi-
(Huang-ti nei ching tai su, cited by Sivin, 1995, p. 15) tioners better understand potential areas of tension
The Chinese people and government are proud of between disciplines, as well as cultural differences in
their historical contributions to medicine and health. approaches to health and wellbeing.
According to the Wudang Taoist Internal Alchemy
(2005), recent additions to a famous temple complex
that dates back to AD 140 include sculptures represent- Historical Use of Occupation
ing historical figures in Chinese medicine (Fig. 1-2). to Heal and Promote Wellbeing
Further evidence of the importance of understanding
The historical actions, beliefs, and practices of humans
and offering acute and preventive care is found in
through the ages also provide an important backdrop
examining long-held practices in India. Ayurveda, the
from which to view the potential to enhance health and
science of life, originated in India about 5000 BC and
wellbeing through engagement in occupation. The use
was later documented by Charak:
of occupation to promote health and wellbeing through
Ayurveda has been reported as one of the oldest sys- prevention of disease, injury, and social injustice has
tems of health care dealing with both the preventive and been substantially documented. Examining lessons
curative aspects of life in a most comprehensive way from the past is time well spent when crafting solutions
and presents a close similarity to the WHOs [World for the present, since we cannot accurately and profes-
Health Organization] concept of health propounded in sionally comprehend the present or look at the future
the modern era. (Department of Ayurveda, 2004, 1). intelligently until we become acquainted with and study
the past (Stattel, 1977, p. 650). Content Box 1-1 out-
lines other benefits of knowing the history of ones

Content Box 1-1

Practical Benefits of an Awareness

of Historical Influences on the
Practice of Occupational Therapy
in Health Promotion
Supports the role of occupational therapy in health
promotion through the realization that foundational
philosophical beliefs and principles can be traced
to the early 1900s.
Enhances awareness of the unique history of
occupation-based interventions for prevention
and health promotion, which increases the com-
fort level of occupational therapists and occupa-
tional therapy assistants in this role.
Encourages the examination of the historical
influence of sociopolitical factors on the evolution
of the profession and its ongoing contributions to
provide solutions to societal problems.
Strengthens societys view of occupational thera-
pists as educated professionals through demonstra-
tion of an appreciation and synthesis of the liberal
arts aspect of occupational therapy education.
Fosters competence to facilitate interdisciplinary
Figure 1-2 Sculpture of ancient Chinese physicians from the
Taiqing Temple Complex, Laoshan Mountain, Peoples Republic cooperation and respect via increased ability to
of China. articulate an understanding of the rich traditions
of occupation-based service delivery.
Photography by S. Maggie Reitz.
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4 SECTION I Foundations and Key Concepts

profession and the political and sociocultural influences European colonists, this society understood the impor-
on that history through time. tance of a lifestyle that balanced the needs of the
History provides a rich description of humans engage- human and nonhuman worlds. This lifestyle included a
ment in occupation for subsistence, self-expression, heal- respect for earth, animals, and humans as well as a
ing, and aesthetics (AOTA, 1979d; MacDonald, 1976; deep sense of responsibility for self and others. Ancient
Pizzi, Scaffa, & Reitz 2006). Through the ages, many sacred sites, often including cave paintings and rock
cultures have used occupations to promote healing. A engravings, represent beliefs regarding origin, attach-
variety of early philosopher-scientists as well as healers ment to the land, and personal and group identity
in Egypt, Rome, Greece, and Persia promoted the use of (Barunga, 1975; Edwards, 1975; Peterson, 1975). The
occupation as a healing agent. Pythagoras and Thales, aboriginal view of social responsibility encompassed
both early Greek philosopher-scientists, used music as a the health and welfare of humans and animals in both
treatment modality (MacDonald, 1976), as did Ibn Sina, the present and the future. The active process of aborig-
a Persian physician, known in the west as Avicenna inal Dreaming embodies values such as prudence
(Ahmed, 1990; Licht, 1948). Aristotle, the pupil of Plato, and social responsibility, which were practiced through
viewed praxis or desirable and satisfying activity or spiritual, learning, and teaching occupations:
action as leading to eudaimonia, the well-being of the
Dreaming is the tracks you are responsible for. You
soul (Friedland, 1998, p. 374).
grow up, then you have to maintain it spiritually. Youve
Physical occupations were often prescribed. The
got to maintain it through not over-using it; youve got
Egyptians recommended physical activity and boat
to do ceremonies for the different animals; youve got to
trips on the Nile (Punwar, 2000) as well as music and
do ceremonies for human beings; and as you grow
games (Dunton, 1954). The Chinese prescribed exer-
and as you get older you learn your responsibilities to
cise to restore wellbeing (Lyons & Petrucelli, 1987)
that area. As you grow older still, and as you marry
and promote health (Levin, 1937). Gymnastics were
into different families, to take on the responsibility of
described by Zhuangzi in fourth-century BC China as a
other people, and as your children have children you
preventive technique to ensure successful aging and
take on the responsibilities of other Dreamingstheir
longevity and became well established as a form of
Dreamings, the childrens Dreamings, which might go
therapy around the third and second centuries B.C.
on a different way from yours. (Bowden & Bunbury,
(Despeux, 1989, p. 241). Hippocrates recommended
1990, p. 33)
other physically challenging occupations, such as
wrestling and riding that required linking the mind and Dreaming is consistent with the aboriginal descrip-
body during treatment (MacDonald, 1976). tion of knowledge as the true aboriginal currency and
In addition to the use of occupations, early public the belief that learning is a lifelong process (Bowden &
health actions and the importance of occupational bal- Bunbury, 1990). To learn more about the ancient and
ance were appreciated as being linked to health and modern culture of the Australian aboriginal people,
wellbeing. Hippocrates encouraged physicians to con- including symbolism in aboriginal art (see Fig. 1-3),
sider the influence of air and water quality in a specific visit http://www.aboriginalart.com.au.
geographical area as well as the occupations of the Indigenous people of North America share this
populationboth healthy and unhealthy. He encour- appreciation for nature, the land, and a desire to live in
aged an examination of the mode of life of the inhab- harmony with the physical world (Kavasch & Baar,
itants, whether they were heavy drinkers, taking lunch, 1999; National Museum of American Indians [NMAI],
and inactive, or athletic, industrious, eating much, and 2005). They also have long shared a belief in the con-
drinking (cited by Lasker & the Committee on Medi- nection of dreams, visions, and rituals to health
cine and Public Health, 1997, p. 12). Pythagoras was (Kavasch & Baar, 1999). Some healing practices have
thought to have promoted health through a special involved occupations such as music, drumming, and,
vegetarian diet (NLM, 2004b, 1). Other historical for the Navajo, sand painting. However, sand painting
figures were proponents of a balanced lifestyle, includ- that can now be purchased as art is not the same in
ing the 13th-century Byzantine writer Actuarius, also either form or function as the sand painting that is cre-
known as John the Actuary (Licht, 1948). In addition, ated for healing purposes. Physically active occupa-
in the fifth century, a neurologist named Caelius Aure- tions such as endurance games and footraces were
lianus encouraged patients to become involved in their believed to enhance the power of other healing prac-
rehabilitation efforts (MacDonald, 1976). tices (Kavasch & Baar, 1999).
Australian aborigines have long recognized the The Wampanoag Indians have lived in eastern
interdependence of human health and welfare with that Massachusetts and the surrounding islands for over
of the land (Chambers, 2002). Prior to the arrival of 12,000 years (Kavasch & Baar, 1999). This group
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 5


h et
Digging stick ty


u b

up of people




Pla e

Honey ant






B us
pl u m

Figure 1-3 Dreamtime symbols used in aboriginal art.

Courtesy of Aboriginal Australia Art & Culture Centre, http://www.aboriginalart.com.au/site_map.html.

shared food-gathering and cultivation knowledge with Bernardino Ramazzini, an 18th-century Italian phy-
the Pilgrims, thus helping the Pilgrims survive. For sician (NLM, 2005) and a professor at Padua, stressed
several hundred years, this group has played Wamp- the importance of prevention rather than treatment
anoag Fireball, a dangerous medicine game that resem- (MacDonald, 1976, p. 5). These early proponents of
bles soccer with a flaming ball. In this game, men occupation, the importance of client-centered care, and
usually young menchannel their strength to enhance the influence of context planted seeds that would later
the healing of a friend or a loved one. The passion and take root in the era of moral treatment and the philosophy
energy expended and the wounds sustained in this of the new discipline of occupational therapy.
game are believed to minimize the impact of ones
illness (Kavasch & Baar, 1999).
Other early medical writers and educators consid- Select Historical Milestones in
ered less dangerous occupations to be useful for both Health Promotion and Prevention
the maintenance of health and illness prevention.
Cornelius Celsus, who lived from 25 BC to AD 50 Within Occupational Therapy
(University of Texas Medical Branch, 2005), encour- in the United States
aged the use of occupations such as sailing, hunting,
handling of arms, ball games, running, and walking to The Birth of the Profession
maintain health (MacDonald, 1976, p. 4). He also The era of moral treatment established the foundat-
encouraged matching occupations to the needs and ion of ideas that would later be embraced by the
temperament of each person. founders of occupational therapy. Moral treatment is
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6 SECTION I Foundations and Key Concepts

a nineteenth-century humanitarian approach to treat- performing self-inoculation through occupation. The case
ment for individuals with mental illness that centered of Barton, one of the founders of occupational therapy in
around productive, creative, and recreational occupa- the United States, is perhaps the most familiar example
tions (Spear & Crepeau, 2003, p. 1031; the history of for occupational therapy practitioners. Isabel Newton,
this approach is discussed in more detail in Chapter 4, also a founder of occupational therapy in the United
which addresses public health). The beliefs and suc- States (Licht, 1967; Neuhas, 1968) and who later
cesses of moral treatment were compatible with the became Bartons wife, described Bartons use of occupa-
visions and optimism of the leaders of various social tion to heal his paralysis. Physicians were so impressed
reform movements in the United States and became the with his results that referrals soon followed (Peloquin,
catalyst for the professions development in the early 1991a). Beers, who was hospitalized in several mental
1900s. Educational reformers, mental hygienists, and institutions over a 5-year period at the beginning of the
leaders in the arts-and-crafts movement shared a phi- 20th century, credits his self-selected engagement in the
losophy stressing the importance and meaning of work occupations of drawing, writing, and reading as con-
and occupation and the resultant potential impact on tributing to his recovery (Peloquin, 1991a). Dunton
learning and health (Breines, 1986). Harold Bell believed patients such as Barton and Beers, who success-
Wright eloquently described the importance of occupa- fully used occupations to aid in their recovery, should be
tion by stating, Occupation is the very life of life acknowledged as contributing to the development of the
(cited by Dunton, 1915, title page). profession (Dunton, 1915; Peloquin, 1991a).
These ideas and values have supported occupa- Sir Winston Churchill, prime minister of Great
tional therapy practitioners engagement in health Britain during World War II, began painting at the age
promotion activities through the years, both with of 40, providing another example of self-inoculation:
individuals and with populations. Those committed to
Winston found hours of pleasure and occupation in
the arts-and-crafts movement saw activity as a means
paintingwhere problems of perspective and colour,
to improve societyto socialize less accepted mem-
light and shade, gave him respite from dark worries,
bers of society such as the disabled, mentally ill,
heavy burdens, and the clatter of political strife. And
impoverished (Schemm, 1964, p. 639, as cited by
I believe this compelling occupation played a part in
Friedland, 1998, p. 375). While occupation was pre-
renewing the source of the great inner strength that
scribed to ill individuals, the power of occupation
was his, enabling him to confront storms, ride out
to promote the overall wellbeing of society was also
depression, and rise above the rough passages of his
recognized early in the professions development:
political life. (Mary Soames, Winston Churchills
Although they spoke of occupation as curative, it was
daughter, Foreword, 2002, pp. viiviii)
not in relation to medical or psychiatric conditions but
rather to the human condition and to use it as a tool Pursuing a variety of occupations provided balance
to maximize human potential for the good of society and perspective to his complex life of military, politi-
(Friedland, 1998, p. 375). cal, and public service. Churchills leadership during
In addition to those who advocated occupation to World War II was instrumental in preventing the inva-
address societal problems, others wrote about the sion of Britain and the expansion of Hitlers Germany,
preventive qualities of occupation. Dunton proposed which were critical in turning the tide of the war. In
that occupation could be used as a preventive agent: recognition of his efforts, Churchill received honorary
Another purpose of occupation may be to give the U.S. citizenship (Frenz, 1969) and was identified as
patient a hobby which may serve as a safety valve and one of the 100 most important people of the century
render the recurrence of an attack less likely (Dunton, (Keegan, 2003). He also received a Nobel Prize for
1915, p. 25). In addition, Dunton also believed that Literature (British Broadcasting Corporation [BBC],
occupation could be a powerful tool for well individu- 2005; Frenz, 1969). An excellent resource summariz-
als, and his work supports the professions use of occu- ing his contributions is listed in the table of website
pation for health maintenance (Peloquin, 1991b). resources at the end of this chapter.
Self-Inoculation Through Occupation The Military and the Use of Occupation
MacDonald noted that the occupational therapist of Military leaders have long recognized the benefits
early history was the doctor himself (1976, p. 2). of using occupation to improve their armies. These
However, through time, it appears that individuals and occupations primarily included physical activities for
communities have self-prescribed occupation both to conditioning and prevention of injury (Kavasch &
heal and prevent illness. Sir Winston Churchill, Clifford Baar, 1999; Levin, 1937) and included entertainment
Beers, and George Barton are examples of individuals to prevent boredom and maintain morale such as has
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 7

been provided by the United Service Organizations deafening sound of shells and grenades exploding. Later
[USO] since 1941 (USO, 2005). it was understood that the symptoms were caused by the
However, occupation does not appear to have been horrific living conditions endured during trench warfare,
used for rehabilitation of soldiers until World Wars which included spending weeks at a time in rat-infested,
I and II. Rehabilitation is not primary prevention; it corpse-laden, and flooded trenches. These conditions are
falls under the categories of secondary and tertiary pre- detailed in an exhibit at the NLM (2004c).
vention. The rehabilitation efforts described below In 1918, Dunton became president of the National
were aimed at the individual needs of soldiers but were Society for the Promotion of Occupational Therapy at
also part of a broader societal intervention through gov- the groups second annual meeting. At that meeting, he
ernmental policy and programs, which can be consid- shared the Europeans success in using occupation to
ered a form of population-based health promotion. treat shell shock and stressed the need for the United
During World War I, it was found in Germany, States to prepare well-trained occupational workers
France, and England that much could be done to recon- for the eventual war effort (Peloquin, 1991b). Within
dition the wounded by means of occupation (Dunton, months, the United States entered World War I, and
1954, p. 5). Early in World War I, before the United recruitment and education for reconstruction aids began
States entered the conflict, leaders in countries already (Dunton, 1954; Peloquin, 1991b; Willard & Cox, 1979).
involved were concerned about the prospect of large Recovering soldiers in World Wars I and II received
numbers of wounded and their need for rehabilitation instructions in basket weaving, woodwork, and other
(Willard & Cox, 1979). The previous system of pension- occupations to facilitate their recovery from physical in-
ing injured veterans for life was not going to be econom- juries and from psychosocial dysfunction caused by the
ically feasible. Thus, there was great interest in ensuring horrors of war (McDaniel, 1968). Figures 1-4 and 1-5
the self-sufficiency of these soldiers (Christensen, 1991). show examples of occupational therapy workshops in a
At the onset of World War I, British physicians began U.S. Army hospital in France during World War I.
to see a cluster of symptoms that became known as shell The exhibit at the NLM mentioned earlier traces
shock. These symptoms included partial paralysis, shell shock from World War I to the Vietnam War,
convulsive movements, blindness, terrifying dreams when the syndrome was labeled Post-Traumatic
and flashbacks, and amnesia (NLM, 2004c, 1). At Stress Disorder, a disorder now recognized by the
first, these symptoms were blamed on exposure to the American Psychiatric Association (NLM, 2004c).

Figure 1-4 Service

provision at U.S. Army
Base Hospital No. 9,
Chateauroux, France.
Courtesy of the National Library
of Medicine (A02826).
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8 SECTION I Foundations and Key Concepts

Figure 1-5 Base Hospital

No. 9. Chateauroux, France,
Courtesy of National Library of
Medicine Collection. Appears as
Figure 24 in Occupational
therapists before World War II
(191740) by M. L. McDaniel
in Army Medical Specialist
Corps (pp. 6997). Washington,
DC: Office of Surgeon General,
Department of the Army.

As often happens, knowledge gained in war can later and experimental projects were carried out in the
be used to favorably affect the health and wellbeing of quest for new occupations to be offered to incapaci-
nonmilitary populations. tated individuals (Barton, 1968, p. 342). An example
of one of the many experiments conducted in the gar-
Early Community and Prevention Practice den area was growing calabash with the expectation
Bartons establishment of Consolation House in 1914 is that patients could turn them into pipes. The philoso-
the earliest example of community-based occupational phy of George Barton and Consolation House can best
therapy practice within the United States (Scaffa, 2001; be expressed through his words:
Scaffa & Brownson, 2005). The doors of Consolation
I am going to raise the cry that it is time for humanity
House opened on March 7, 1914, after extensive alter-
to cease regarding the hospital as a door closing upon
ations. In an article commemorating AOTAs 50th anniver-
a life which is past, and to regard it henceforth as a
sary, Bartons wife, Isabel, described the alterations and
door opening upon a life which is to come. I do not
the dedication of the Consolation House (Barton, 1968).
mean heaven. I mean a job, as better job, or a job done
The alterations included a 6-foot tub, which Barton
better than it was before. (Barton, 1968, pp. 34243)
installed against the advice of the plumber. After many
months at a sanatorium, Barton desired the opportunity Consolation House was the model for the present-day
to stretch out while bathing. The parlor of the house University of Southern California (USC), Department of
was turned into an office that housed books related to Occupational Science and Occupational Therapys Cen-
occupational therapy as well as a glass case exhibiting ter for Occupation and Lifestyle Redesign (Gourley,
patients craft work. The dcor of Consolation House 2000; Krieger, 2001). The center was established in
was heavily influenced by the arts-and-crafts movement 1999 (USC, 2004) in a renovated 1894 Victorian man-
of the early 1900s (Krieger, 2001). sion (Krieger, 2001) and is used for community-based
The first floor of an old red barn on the property was practice, education, and research. Workshops modeled
converted into a workshop, and the second floor after Bartons program and the Hull Houses work with
became a studio. Barton acquired a vacant lot adjacent immigrants are geared primarily for the local Latino
to the house and subdivided it into three sections: a community (Krieger, 2001).
vegetable garden, a grass lawn, and an area containing In the United States, occupational therapys early
flowering shrubbery and a hammock. The house pro- work in prevention focused on the prevention of infec-
vided tools for engaging in a variety of occupations, tious disease such as tuberculosis (TB). Diaz (1932)
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 9

described her efforts to organize a preventorium in advantage of being in the community as an opportunity
Puerto Rico for children of parents with TB, with the to minimize adverse health conditions and prevent
goal of decreasing the childrens risk of contracting the future illness in other family or community members,
disease. The board of directors of an association to pre- thereby joining the public health team.
vent TB among children contacted Diaz to organize The use of occupation to promote normal develop-
a new facility to house and care for 50 children ment was also recognized early in the professions evo-
between the ages of 2 and 10. Diaz performed a variety lution. Manual, recreational, and musical occupations
of administrative functions, including the development were recommended for use with children in the 1940s:
of a daily regimen of habit training and occupations
Activities used with children should be chosen primar-
that included marching, sun-baths, singing, folk danc-
ily for their therapeutic value, but at the same time the
ing, rest in bed, story telling, calisthenics, outdoor
possibilities for a normal development of the child
games, daily prayers, personal habits . . . academic
should be considered and activities of positive value
classes, and some craft work (Diaz, 1932, p. 200).
should be chosen to encourage this development.
Within a 1-year period, the progress of the children was
(Gleave, 1954, p. 163)
reported as remarkable. They entered the institution in
very bad condition: undernourished, unhealthy, and
with little or no discipline. They were returned quite Visionary Leaders and Modern Milestones
different (Diaz, 1932, p. 201). in Health Promotion
Shaffer, a psychologist, presented a paper at the 21st Occupation was also seen as a preventive tool for the
annual meeting of the AOTA on recreation for preven- hospitalized patient. Fay and Kellogg (1954) described
tion and therapy for social maladjustments. He argued one of the roles of occupational therapy as the pre-
that access to healthy play would facilitate childrens vention of the establishment of invalid habits by giving
development and prevent criminal habits and mental opportunity for establishing or maintaining good
illness. He was concerned about the then-current prac- work habits. The benefits of engaging occupational
tice of sheltering children from vigorous activity. Play, therapy were identified as improvement in circulation,
he believed, properly engaged in, is habit training for decrease in fatigue, good sleep, good appetite, and
the more serious problems of adult living (Shaffer, good posture (p. 118).
1938, p. 98). Team play was also viewed as beneficial, Although these were important efforts, they were
with the child learning how to subordinate his desires falling short of the full potential that the profession
to the common good and to develop loyalty to a of occupational therapy had to offer. This was readily
purpose or a task undertaken. Thus he is learning apparent to visionaries such as Wiemer. Wiemer repeat-
the important secrets of a good adjustment to life edly stressed her concern (1972) that the profession was
(Shaffer, 1938, p. 98). viewing its role in prevention in a too limited, elemen-
Prevention was mentioned intermittently in the tary manner and that the description of the role appeared
literature in the 1940s both within Canada and the to be mere technical responses rather than professional-
United States. Dr. Howland, the first president of level problem-solving. Wiemer encouraged the profession
the Canadian Association of Occupational Therapists, to expand efforts across the preventive-health continuum.
identified prevention as one of five forms of occupa- Figure 1-6 displays Wiemers Preventive Health Contin-
tional therapy (Friedland, 1998). In 1947, the director uum functions matched to the three levels of prevention
of the Philadelphia Committee for the Prevention of primary, secondary, and tertiary.
Blindness discussed the need for interdisciplinary col- In Wiemers view, the appropriate role of occupa-
laboration to prevent blindness through combating its tional therapy should encompass
three primary causes: venereal disease, now referred to
the clear exercise of that expertise unique to occupational
as sexually transmitted infection; glaucoma; and acci-
therapy, needed by society, and unavailable from other
dents (Carpenter, 1947). Carpenter believed occupa-
sources, exerting all components of occupational ther-
tional therapists, due to their interactions with families,
apys armamentarium impinging upon prevention rather
had a key role in the early screening of visual problems
than selected options from it, with imaginative action to
in children and their parents (Reitz, 1992). Specifically,
supplement and complement efforts of other disciplines
occupational therapists were encouraged to look for
[italics are original authors]. (Wiemer, 1972, p. 5)
and intervene when symptoms of congenital syphilis or
ineffective home remedies for injured eyes were pre- Wiemer also noted that this role would require a
sent, or if they heard reports of family members or change in philosophy. Occupational therapists would
neighbors seeing colored rings around lights at night. need to broaden their perspective regarding who they
Occupational therapists were also encouraged to take were responsible forswitching their focus from
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10 SECTION I Foundations and Key Concepts

assuming responsibility for patients treated to persons Also in the 1980s, articles appeared in the occupa-
they do not treat (Wiemer, 1972). This statement also tional therapy literature regarding the potential role of
holds true for current practice, as the profession largely occupational therapy in workplace injury prevention.
remains reimbursement driven. The profession has Allen (1986) reviewed two programs addressing the
renewed its commitment to improve the health and impact of repetitive work injury on workers and
wellbeing of society, which will be demonstrated employers. The first was a seven-session program deliv-
through examples and discussions of official docu- ered to bank employees and consisting of recommen-
ments in the next section of this chapter. dations to modify the work environment and work
The 1980s saw the publication of numerous articles habits for efficiency and effectiveness. The second was
regarding prevention and health promotion. The director a luncheon lecture program for university employees
of AOTAs Practice Division presented current trends that and addressed modifying life-style, posture, equip-
were impacting the practice of the profession. Woven ment, desk arrangement, and work organization
through this discussion was support for the prediction (Allen, 1986, p. 766).
that wellness and prevention concepts will become Schwartz (1989) described the role of occupational
increasingly accepted for philosophical and economical therapy in industrial accident and injury prevention.
reasons (Bair, 1982, p. 704). Articles describing pro- Many areas of expertise required for competence in this
gram outcome studies were published, providing data for role were identified, including knowledge of the business
evidence-based practice and ideas for future research. world (i.e., labor relations, corporate and industrial man-
Two of these studies were conducted with children agement, economics), biological science (i.e., neuro-
one with preschoolers in the United States (George, sciences, kinesiology, pathology), social science, and
Braun, & Walker, 1982) and one with infants in Israel education. Schwartz predicted an explosive demand for
(Parush, Lapidot, Edelstein, & Tamir, 1987). Both studies prevention services. Whether called wellness, risk man-
concluded that structured occupation-based programs agement, and cost containment, or something else, it is
developed by occupational therapists can enhance the going to become economically and legally imperative
development of age-appropriate skills. In addition, a that employees act to prevent accidents and injuries
study was conducted with healthy older adults to deter- (1989, p. 6). This prediction was partially realized within
mine the effectiveness of occupational therapy interven- the following decade, as the author increasingly saw
tion on self-care independence and quality of life retail employees wearing protective gear, though often
(Kirchman, Reichenbach, & Giambalvo, 1982). Results incorrectly and inconsistently.
suggest that the intervention had a positive impact on The AOTAs backpack awareness campaign (AOTA,
social resources, life satisfaction, and general affect. 2004; Gourley, 2001a, 2001b) is another example of

Prevention/Health Promotion

Primary Prevention Secondary Prevention Tertiary Prevention

Promotion Protection Identification Correction Accommodation

Education in Interception Locating illness, Treatment of Adaptation of

support of of agents and preventing illness and person with illness
good health conditions advancement disability Changing
Health Isolation of disease Treatment and environment
education Immunization Multiphasic rehabilitation Altering
Eradication of Accident screening of acute, customs
taboos and prevention Consultancy chronic, or Interpreting
cultural habits evaluations degenerative medical facts
Training in Physical exams disease Counseling
hygiene and Diagnostic families
activities to workups
promote health
Figure 1-6 Wiemers Preventive Health Continuum matched to the three levels of prevention.
Developed from Wiemer (1972), by Reitz (1984, 2004) with permission.
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 11

occupational therapys potential for preventing injury. Official Documents and Activities
These preventive initiatives demonstrate the potential
for occupational therapy to be involved in primary pre- of AOTA Related to Health
vention at the level of the individual, the classroom, or Promotion and Prevention
the educational institution.
In the late 1990s, Wilcock and Townsend, as was Examples of practitioners use of occupation in
earlier the case for Wiemer, articulated a vision for community-based practice and prevention from the
occupational therapy to contribute to the health and professions inception through the mid-20th century in
wellbeing at a societal level (Townsend, 1999; Wilcock, the United States were provided above. The ability of
1998; Wilcock & Townsend, 2000). In 2000, Wilcock humans to maximize their health through engagement
described the impact of occupational science on her in occupations was discussed repeatedly in the litera-
philosophy and work (Wilcock, 2000). The interna- ture during this time period (Brunyate, 1967; Finn,
tional team of Townsend and Wilcock introduced the 1972, 1977; Jaffe, 1986; Johnson, 1986a, 1986b; Reilly,
constructs of occupational justice, occupational injus- 1962; West, 1967, 1969; Wiemer, 1972), including in
tice, and other terminology to provide a language for several Eleanor Clarke Slagle lectures (Table 1-1). The
occupational therapy assistants and occupational thera- discussion will now turn to an examination of official
pists to use as they examined broader societal and AOTA documents and activities, including the vision-
global issues through the lens of occupation. These ary leadership of Brunyate (ne Wiemer) and others. A
ideas are introduced and defined in the context of pop- timeline of these key events appears in Table 1-2.
ulation health in Chapter 6 and are also addressed dur-
ing a discussion of occupational justice in Chapter 8. Report of the Task Force on Social Issues
Toward the end of the 1990s, a milestone in the pro- In the 1970s, the AOTA established a task force to iden-
fessions history was reached with the publication of tify major changes occurring within the social system
the USC Well Elderly Study in the prestigious Journal and the health care systems in order to evaluate the
of the American Medical Association (Clark et al., directions and contributions of occupational therapy
1997). This study investigated the effectiveness of the (AOTA, 1972, p. 332). Ten trends (shown in Content
USC Well Elderly program. Results indicated that Box 1-3) were identified as possible influencing factors
preventive occupational therapy greatly enhances the on changes in health care in the next decade. Two of
health and quality of life of independent-living adults. these trends included
This landmark study reaffirmed foundational principles
of occupational science and occupational therapy 1. national health insurance and legislation, and
(Mandel, Jackson, Nelson, & Clark, 1999, p. xi). The 2. new attitudes toward health care.
program was based on fundamental beliefs of the occu- Echoing Plato, the task force stressed that preventive
pational therapy profession (see Content Box 1-2) as approaches were as necessary as medical approaches.
well as theoretical perspectives from the academic The task force also described alternatives for the future of
discipline of occupational science. A complete descrip- occupational therapy. Occupational therapy services
tion is available through an AOTA publication (Mandel were described using the five functions identified in
et al., 1999). Wiemers (1972) preventive health care continuum (i.e.,
promotion, protection, identification, correction, and
Content Box 1-2 In 1979, Wiemer criticized the simplistic nature
of the services described in the task force report,
Core Ideas From Occupational Ther- believing they fell short of the true potential of occu-
apy That Framed Lifestyle Redesign pational therapy:
Occupation is life itself.
Occupation can create new visions of possible My prior plea for attention to occupation regrettably
selves. resulted in action tangential to my point. In quoting my
Occupation has a curative effect on physical and thoughts, the Task Force on Social Issues suggested:
mental health and on a sense of order and routine. for example,
Occupation has a place in prevention. a. One of the highest accident rates occur in the home,
From Lifestyle redesign: Implementing the well elderly study (p. 13) by therefore occupational therapists might participate
D. R. Mandel, J. M. Jackson, R. Zemke, L. Nelson, & F. A. Clark, in public education programs to help people become
1999, Bethesda, MD: American Occupational Therapy Association.
With permission. Copyright 1999 by American Occupational
aware of the dangers of slippery rugs, slippery
Therapy Association. floors, and other hazards.
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12 SECTION I Foundations and Key Concepts

Table 11 Eleanor Clarke Slagle Lectures With Health Promotion Themes and Constructs

Year Lecturer Title Themes

1961 Mary Reilly Occupational Therapy Can Be Humans can impact their own health and wellbe-
One of the Greatest Ideas of ing through engagement in meaningful occupations.
20th-Century Medicine
1967 Wilma L. West Professional Responsibility The role of current occupational therapy should
in Time of Change be broadened from the medical model by prepar-
ing practitioners to serve society by being health
1969 Lela A. Llorens Facilitating Growth & Occupational therapy can promote healthy growth
Development: and development.
The Promise of Occupational
1971 Geraldine L. Finn The Occupational Therapist The need for and issues that must be addressed
in Prevention Programs to develop occupational therapys role in preven-
tion programs.
1972 Jerry A. Johnson Occupational Therapy: Occupation can be used to impact individual and
A Model for the Future societys need for health. Profession needs to
predict changes in society so its practitioners can
be prepared to make contributions to the ever-
changing world.
1980 Carolyn Manville Occupational Therapists Practitioners need to be prepared to enter different
Baum Put Care in the Health arenas in health care, other than acute care.
System Examples include public health, hospital-based
community outreach, and embedding prevention
within curative programs.
1984 Elnora M. Gilfoyle Transformation of a A paradigm shift is occurring with the society and
Profession the profession. The profession needs to continue
to decrease its reliance on the patriarchal medical
model and develop its potential to impact the
wellbeing of individuals and society.
1990 Susan B. Fine Resilience and Human Occupation can be used as a tool to facilitate
Adaptability: Who Rises resilience and wellbeing in the face of traumatic
Above Adversity? life events.
1994 Ann P. Grady Building Inclusive Community: Promoting inclusion in communities of choice for
A Challenge for Occupational individuals at the local and global level promotes
Therapy adaptation, participation, and wellbeing for indi-
viduals with and without disabilities.
1996 David L. Nelson Why the Profession of Engaging in meaningful occupation can promote
Occupational Therapy health and quality of life.
Will Flourish in the
21st Century
2004 Ruth Zemke Time, Space, and the Importance of temporal rhythms, and their
Kaleidoscopes of Occupation interactions with space, place, and culture to
human health.
2006 Betty R. Hasselkus The World of Everyday Engagement in everyday occupations can promote
Occupation: Real People, health and wellbeing. The detrimental impact
Real Lives of limits to occupational engagement.
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 13

Table 12 Selection of Key Highlights in AOTAs Historical Involvement in Health Promotion

and Disease Prevention
Year Event Reference

1915 Dunton proposes that occupation can be a preventative agent. (Dunton, 1915)
1932 American Journal of Occupational Therapy (AJOT) publishes (Diaz, 1932)
an article titled Organizing a Preventorium for Children.
1947 AJOT publishes an article on prevention of blindness. (Carpenter, 1947)
1961 Reilly proposes that humans can impact their health through (Reilly, 1962, p. 1)
occupation: Man, through the use of his hands as they are
energized by mind and will, can influence the state of his
own health.
1968 Revised AOTA definition includes the phrase to promote (Willard & Spackman, 1971, p. 1)
and maintain health, to prevent disability.
1972 AOTA Task Force established to delineate a model of practice (Jaffe, 1986, p. 11)
for prevention and health maintenance programs.
1977 AOTA Representative Assembly (RA) passed Resolution (Jaffe, 1986)
No. 521-77, Preventive Health Care Services.
1978 AOTA RA approved the Philosophical Base of Occupational (AOTA, 1979c, p. 785)
Therapy, which included the phrase (occupation) may be
used to prevent and mediate dysfunction.
1978 AOTA RA convened a special session; the result was the (AOTA, 1979b)
monograph Occupational Therapy 2001: AD.
1986 First AJOT special issue on health promotion. (AOTA, 1986)
1988 AOTA appoints first health promotion/wellness program (A. Morris, personal communication,
manager. July 1989)
1989 AOTA RA approved the position paper Occupational Therapy (AOTA, 1989a)
in the Promotion of Health and Prevention of Disease
and Disability.
1989 AOTA representatives participate in the meeting of the U.S. (AOTA, 1989b)
Year 2000 Health Objectives Consortium.
2000 AOTA RA approved Occupational Therapy in the Promotion (Brownson Scaffa, 2001)
of Health and the Prevention of Disease and Disability.
2007 AOTA RA approved AOTAs Statement on Stress and Stress (Stallings-Sahler, 2007)
2007 AOTA RA approved Occupational Therapy Services in the (Scaffa et al., 2008)
Promotion of Health and the Prevention of Disease and

Modified from The historical and philosophical bases for occupational therapys role in health promotion, presentation by S. M.
Reitz at the 10th International Congress of the World Federation of Occupational Therapists, Melbourne, Australia, April 3, 1990.

b. Adolescents have a high accident rate, and parents various types of occupation, or lack of it, and the fact of
and adolescents might be warned of the dangers of the fall or driving accident; facts indicating, for exam-
permitting or encouraging adolescents to drive high ple, the relationship between boredom, carelessness,
speed cars, . . . and falling, or between fast driving and the nature of the
Any parent, spouse, sibling, or TV commercial can do occupational experiences of teenagers. (Wiemer, 1979,
that! We need to show causal relationships between pp. 4445)
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14 SECTION I Foundations and Key Concepts

Content Box 1-3 AOTA Official Statements on Prevention

and Health Promotion
Ten Trends Identified by AOTA Task The AOTA has published four statements on the profes-
Force That May Have an Impact on sions role in health promotion. The first was titled
Health Care in the 1970s Role of the Occupational Therapist in the Promotion
National health insurance and legislation
of Health and Prevention of Disabilities (AOTA,
Changing attitudes toward health care 1979a). The second, Occupational Therapy in the
Changing educational patterns Promotion of Health Care and the Prevention of Dis-
Change in educational consumer ease and Disability, followed 10 years later (AOTA,
Changing patterns of work-leisure 1989a). The next most recent version was titled Occu-
Changes in housing and living patterns, styles of
life, and living conditions
pational Therapy in the Promotion of Health and the
Technology and daily living Prevention of Disease and Disability Statement
The feminist movement (Brownson & Scaffa, 2001). The most recent version is
Technology changes affecting career patterns and titled Occupational Therapy Services in the Promo-
places of living tion of Health and the Prevention of Disease and Dis-
Transmission of knowledge
ability (Scaffa, Van Slyke, Brownson, & American
From Report of the task force on social issues, by J. A. Johnson, Occupational Therapy Association, 2008).
Chairman, Task Force, 1972, American Journal of Occupational An evolution in the professions knowledge and
Therapy, 26, pp. 33337. With permission. Copyright 1972 by
American Occupational Therapy Association. application of prevention and health promotion can be
traced by reviewing the aforementioned documents.
The introductory section of the first document (AOTA,
The profession has begun to answer Wiemers chal- 1979a) included two significant quotations. The first of
lenge with a return to occupation-based practice and these was the oft-quoted World Health Organization
the implementation of broader initiatives such as the (WHO) definition of health, which is the complete
USC Well Elderly program, which provides evidence state of physical, mental, and social wellbeing, and not
for practice. Continued progress is needed in idea just the absence of disease or infirmity (WHO, 1947,
formation and interventions at the broader policy and p. 29). The second is Reillys famous statement that
population levels. man, through the use of his hands as they are ener-
gized by mind and will, can influence the state of his
American Journal of Occupational Therapy own health (Reilly, 1962, p. 1). This two-page role
Special Issue statement was the first AOTA document to be adopted
This first-ever special issue on health promotion of the by the Representative Assembly on prevention and
American Journal of Occupational Therapy included health promotion and thus institutionalized the vision
articles on a variety of subjects related to health pro- of its leadership (Brunyate, 1967; Finn, 1972, 1977;
motion (AOTA, 1986). Topics included educational Reilly 1962; West, 1967, 1969; Wiemer, 1972). The
needs, potential role, cost and benefits of program- second version of the document was reduced to a one-
ming, and the best practice examples of that time. page, five-paragraph document that focused on defin-
The guest editor of the issue defined terminology, the ing and differentiating between the terms health
need for outcome measures, and other issues in health promotion and wellness (AOTA, 1989a). The term
promotion. wellness was increasingly being used by both lay and
health professionals during this time.
2000 Health Consortium The third version (Brownson & Scaffa, 2001) contin-
In 1989, two AOTA representatives (Anne Long Morris ued to define wellness, health promotion, and three levels
and Evelyn Jaffe) participated in a meeting of the 2000 of prevention (i.e., primary, secondary, and tertiary), and
Health Objectives Consortium sponsored by the Insti- the WHO definition of health. New terms that have
tute of Medicine and U.S. Public Health Service emerged within the discipline, such as lifestyle redesign,
(AOTA, 1989b). This meeting was one of many activi- also were defined. Readers were introduced to the U.S.
ties in the development of the health objectives for national health agenda through a description of Healthy
Healthy People 2000: National Health Promotion and People 2000 and Healthy People 2010. In addition, this
Disease Prevention Objectives (U.S. Department of version provides examples of individual-level, group-
Health and Human Services [USDHHS], 1990). More level, organizational-level, community/societal-level, and
details regarding other U.S. governmental health- governmental/policy-level occupation-based interven-
promotion initiatives, including Healthy People 2010: tions. This list of interventions was a resource for occu-
Understanding and Improving Health (USDHHS, pational therapists and occupational therapy assistants
2000), appear in Chapter 4. considering such work.
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 15

The current 10-page statement (Scaffa et al., 2008) intervention process that facilitates engagement in occu-
continues to define health promotion and the three levels pation to support participation in life (AOTA, 2002,
of prevention and builds on the foundation of the earlier p. 609). This document provides the structure to support
works. The new version provides detailed examples of health promotion interventions at multiple levels, includ-
occupational therapy strategies at each level of preven- ing context, performance patterns, and performance
tion. In addition, it expands the discussion of the role of areas (i.e., education, work, play, leisure, and social par-
occupational therapy practitioners at the level of the in- ticipation). Although individuals are the focus of inter-
dividual, community, population, and organization as vention approaches outlined in the tables located in the
well as at the governmental and policy levels. A new fea- Frameworks appendix, the document defines the terms
ture, case studies, is used to provide details regarding the client and prevention more broadly than the individual
assessment and intervention process in occupational level. See Table 1-3 for these and related definitions
therapy health promotion practice. The current statement (i.e., health promotion, disability prevention, and
includes a discussion of the professions unique contri- wellness). The use of these definitions and language
bution in this area (see Content Box 1-4). that is consistent with the World Health Organizations
International Classification of Functioning, Disability
Occupational Therapy Practice Framework: and Health (ICF) (WHO, 2001) helps the profession
Domain and Process (Framework) make the shift to the new health system paradigm as
The capacity for the profession to contribute to health described by Baum and Law (1997) in Table 1-4.
promotion and to disease and disability prevention is
supported by the document Framework (AOTA, 2008). Centennial Vision
The Framework was developed in order to more clearly In 2003, the AOTA board of directors endorsed the
articulate occupational therapys unique focus on occu- development of a Centennial Vision to act as a road
pation and daily life activities and the application of an map for the future of the profession (Christiansen,
2004, p. 10). This effort is reminiscent of the work of
the 1970 Task Force on Social Issues (AOTA, 1972),
discussed earlier in this chapter and the long-range
Content Box 1-4 planning as advocated by Bair (1982). The goal of this
2-year process was to develop a plan that would
Occupational Therapys Unique
Contribution to Health Promotion ensure that individuals, policymakers, populations,
and society value and promote occupational therapys
and Disease/Disability Prevention practice of enabling people to prevent and overcome
Evaluate occupational capabilities, values, and obstacles to participation in the activities they value, to
performance prevent health related issues, improve their physical
Provide education regarding occupational role
performance and balance and mental health, secure well-being, and enjoy a
Reduce risk factors and symptoms through higher quality of life. (Christiansen, 2004, p. 10)
engagement in occupation
Provide skill development training in the context of The first step in the development of the Centennial
everyday occupations Vision was a scenario-building process that took place in
Provide self-management training to prevent October 2004 (Brachtesende, 2004). Various AOTA lead-
illness and manage health ers and a small number of international representatives
Modify environments for healthy and safe occupa- were invited to participate in this early stage of the Cen-
tional performance
Consult and collaborate with health care profession- tennial Vision development. From this process, four pos-
als, organizations, communities, and policymakers sible scenarios were developed. Details regarding each
regarding the occupational perspective of health scenario and the anticipated trends impacting the profes-
promotion and disease or disability prevention sion are available on the AOTA website. It is expected
Promote the development and maintenance of that the Centennial Vision effort will expand the current
mental functioning abilities through engagement
in productive and meaningful activities and rela- view of the professions role in fostering healthier indi-
tionships (adapted from USDHHS, 1999, p. 4) viduals, families, communities, and society.
Provide training in adaptation to change and in
coping with adversity to promote mental health
(adapted from USDHHS, 1999, p. 4) Conclusion
From Occupational therapy in the promotion of health and the preven- The historical use of occupation by many cultures to
tion of disease and disability statement, by C. A. Brownson & M. E. heal, promote health, and prevent injury and disease has
Scaffa, 2001, American Journal of Occupational Therapy, 55, pp.
65660. With permission. Copyright 2001 by American Occupational been well chronicled. Occupational therapys many and
Therapy Association. varied contributions to health promotion and disease
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16 SECTION I Foundations and Key Concepts

Table 13 Select Health Promotion Terms and Definitions From the AOTA Frameworks

Term Definition
Client The entity that receives occupational therapy services. Clients may include (1) individu-
als and other persons relevant to the individuals life, including family, caregivers, teach-
ers, employers and others who also may help or be served indirectly; (2) organizations
such as business, industries, or agencies; and (3) populations within a community
(Moyers & Dale, 2007 cited by AOTA, 2008, p. 669).
Disability prevention An intervention approach designed to address clients with or without a disability who
are at risk for occupational performance problems. This approach is designed to prevent
the occurrence or evolution of barriers to performance in context. Interventions may be
directed at client, context, or activity variables (adapted from Dunn et al., 1998 cited by
AOTA, 2008, p. 659).
Health promotion Creating the conditions necessary for health at individual, structural, social, and environ-
mental levels through an understanding of the determinants of health: peace, shelter,
education, food, income, a stable ecosystem, sustainable resources, social justice, and
equity (Trentham & Cockburn 2005, cited by AOTA, 2008, p. 671).
Prevention Promoting a healthy lifestyle at the individual, group, organizational, community
(societal), governmental/policy level (adapted from Brownson & Scaffa, 2001 AOTA,
2002, p. 633 and AOTA, 2008, p.674).
Wellness Wellness is more than a lack of disease symptoms. It is a state of mental and physical
balance and fitness (adapted from Tabers Cyclopedic Medical Dictionary, 1997, in AOTA,
2002, p. 628 and AOTA, 2008, p. 676).

Compiled from Occupational therapy practice framework: Domain and process, by the American Occupational Therapy Association,
2002, Bethesda, MD: Author; Occupational therapy practice framework: Domain and process (2d ed.), by the American Occupational
Therapy Association, 2008, Bethesda, MD: Author. Copyright 2002, 2008 by American Occupational Therapy Association.

Table 14 A Changing Health System Paradigm

Area Old Medical Model

The Model Sociopolitical (community) model Planned or managed health
The Focus Focus on illness Focus on wellness
Acute care outcomes Wellbeing, function, and life satisfaction
Individual Individual within the environment
Deficiency Capability
Survival Functional ability, quality of life
Professionally controlled Personal responsibility, flexible choice
Dependence Interdependence, participation
Treatment Treatment, prevention
The System Institution centered Community centered
Single facility Network system
Competitive focus Collaborative focus
Fragmented service Coordinated service

From Table 1 in Occupational therapy practice: Focusing on occupational performance, by C. M. Baum and M. Law, 1997,
American Journal of Occupational Therapy, 51, p. 281. Copyright 1997 by American Occupational Therapy Association.
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Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 17

and disability prevention are extensively documented. prescribing occupations for healing and health? Or
This historical information was reviewed as a founda- might it result in further separation from the potential
tion for future efforts in health promotion and preven- to serve society and eradicate occupational injustices?
tion of disease and disability. 3. Review AOTAs Centennial Vision home page
Interdisciplinary efforts are essential to maximize (http://www.aota.org/nonmembers/area16/index.asp)
the benefits of occupational therapists and occupa- and the four possible future scenarios. What do you
tional therapy assistants on the health of individuals, see as occupational therapys possible contributions
families, communities, and populations. Health pro- to societys wellbeing for one of these four scenarios?
motion is performed by a variety of trained individu-
als; it is not unique to a specific profession. The need
for the profession to work collaboratively with other Research Questions
disciplines was recognized decades ago. It was 1. By way of a document analysis, how does the
believed the professions expertise and historical con- frequency of articles on issues of occupational
cerns for health and service can best be actualized and social justice in the American Journal of
through interdisciplinary collaboration (MacDonald, Occupational Therapy compare to other interna-
1976). These collaborative efforts can result in more tional journals?
efficacious outcomes that include occupation as a rec- 2. How does the development of interest in the pre-
ognized, legitimate tool. ventive aspects of occupation in the United States
There is much for U.S. occupational therapy practi- compare to other countries in South America,
tioners to learn through involvement with the interna- Southeast Asia, and Europe?
tional occupational therapy community. Knowledge can
be gained through exposure to international literature
(e.g., Occupational Therapy without Borders: Learning Occupational Engagement
from the Spirit of Survivors [Kronenberg, Algado, &
Pollard, 2005], British Journal of Occupational Therapy, Assignments to Enhance
Israeli Journal of Occupational Therapy, Journal of Appreciation of the Historical
Occupational Science, South African Journal of Occupa- Role of Occupational Therapy
tional Therapy), websites (e.g., Australian Association of
Occupational Therapists, Canadian Association of Occu- in Health Promotion
pational Therapists, European Network of Occupational 1. Select five objects that you would put in a time
Therapy in Higher Education, World Federation of Occu- capsule (to be opened in 50 years) to capture the
pational Therapists), and by attending international con- current state of occupational therapy health
ferences. Although countries have differing political and promotion practice. Explain your selections.
economic ideologies, they share many common health 2. Develop a 15-minute skit that depicts time travel-
promotion and prevention concerns. As a profession, occu- ers observations and reflections of occupational
pational therapy has much to contribute to the global health therapy interventions directed toward health and
and wellbeing of citizens and populations through kno wellbeing in at least two different time periods.
wledge of the healing and preventive qualities of occupa- 3. Develop a presentation that portrays the leaders in
tion. Innovative health-promoting strategies are likely to occupational therapy from any period in time and
emerge through international and interdisciplinary collab- highlights the impact of then-current political and
oration, maximizing the contributions of all involved. social contexts on their professional activities.

For Discussion and Review References

1. As discussed in this chapter, Greek mythology had
separate goddesses for healing (Panacea) and for Ahmed, M. (1990, November). Ibn Sina (Avicenna)Doctor
health (Hygeia). Does this divisionsymbolized in of doctors. Muslim Technologist.Retrieved December 4,
2004, from http://www.ummah.net/history/scholars/
ancient Greek mythcontinue in occupational ibn_sina/.
therapy practice today? Allen, V. R. (1986). Health promotion in the office. American
2. As quoted earlier, the occupational therapist of early Journal of Occupational Therapy, 40(11), 76470.
history was the doctor himself (MacDonald, 1976, American Occupational Therapy Association. (1972). Report of
p. 2). Will the advent of clinical doctorates enable the Task Force on Societal Issues [J. A. Johnson, Chairman].
occupational therapy to return to the role of American Journal of Occupational Therapy, 26(7), 33259.
1193_Ch01_001-021.qxd 6/8/09 5:30 PM Page 18

18 SECTION I Foundations and Key Concepts

American Occupational Therapy Association. (1979a). Associ- Breines, E. (1986). Origins and adaptations: A philosophy of
ation official position paperRole of the occupational ther- practice. Lebanon, NJ: Geri-Rehab.
apist in the promotion of health and the prevention of British Broadcasting Corporation (BBC). (2005). Historic fig-
disabilities. American Journal of Occupational Therapy, ures: Sir Winston Churchill (18741965). Retrieved
33(1), 5051. December 6, 2005, from www.bbc.co.uk/history/
American Occupational Therapy Association. (1979b). Occu- historic_figures/churchill_winston.shtml.
pational therapy: 2001 AD. Rockville, MD: Author. Brownson, C. A., & Scaffa, M. E. (2001). Occupational ther-
American Occupational Therapy Association. (1979c). Repre- apy in the promotion of health and the prevention of disease
sentative assembly minutes: New businessResolutions, and disability statement. American Journal of Occupational
Resolution C, the philosophical base of occupational therapy. Therapy, 55(6), 65660.
American Journal of Occupational Therapy, 33(11), 785. Brunyate, R. W. (1967). From the president: After fifty years,
American Occupational Therapy Association. (Producer; what stature do we hold? American Journal of Occupational
1979d). The early years [video]. Therapy, 21(5), 26267.
American Occupational Therapy Association. (1986, November). Carpenter, E. M. (1947). Considerations for prevention of
Special issue of health promotion. American Journal of blindness and conservation of vision. American Journal of
Occupational Therapy, 40. Occupational Therapy, 1(6), 34851.
American Occupational Therapy Association. (1989a). Occupa- Chambers, J. H. (2002). A travelers history of Australia
tional therapy in the promotion of health care and the pre- (2nd ed.). New York: Interlink.
vention of disease and disability (position paper). American Christensen, E. (1991). A proud heritage: The American Occu-
Journal of Occupational Therapy, 43(12), 806. pational Therapy Association at seventy-five. Rockville,
American Occupational Therapy Association. (1989b, December 7). MD: American Occupational Therapy Association.
Year 2000 health consortium meets. OT Week, 9. Christiansen, C. (2004, September 20). AOTAs Centennial
American Occupational Therapy Association. (2002). Occupa- Vision: A map for the future. OT Practice, 9(17), 10.
tional therapy practice framework: Domain and processes. Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandela,
American Journal of Occupational Therapy, 56, 60939. D., Hay, J., Josephson, K., Cherry, B., Hessel, C., Palmer, J., &
American Occupational Therapy Association. (2004). National Lipson, L. (1997). Occupational therapy for independent-living
school backpack awareness day 2004. Retrieved February older adults: A randomized controlled trial. Journal of the
26, 2005, from http://www.promoteot.org/AI_Backpack American Medical Association, 278(16), 131226.
Awareness.html. Department of Ayurveda, Yoga Naturopathy, Unani, Siddha,
American Occupational Therapy Association. (2005). AOTAs and Homoeopathy, Ministry of Health & Family Welfare,
Centennial Vision: Shaping the future of occupational ther- Government of India. (2004). AyurvedaIntroduction:
apy, planning scenarios for 2017. Retrieved December 6, Origin and history. Retrieved December 20, 2004, from
2005, from http://www.aota.org/nonmembers/area16/ http://indianmedicine.nic.in/html/ayurveda/ayurveda.htm#
links/link02.asp. Introduction.
American Occupational Therapy Association. (2008). Occupa- Despeux, C. (1989). Gymnastics: The ancient tradition. In
tional therapy practice framework: Domain and processes L. Kohn (ed.), Taoist meditation and longevity techniques
(2d ed.). American Journal of Occupational Therapy, 62, (pp. 22561). Ann Arbor, MI: Center for Chinese Studies,
62588. University of Michigan.
Anderson, K. N., Anderson, L. E., & Glanze, W. D. (1998). Diaz, M. P. (1932). Organizing a preventorium for children.
Mosbys medical, nursing, allied health dictionary (5th ed.). Occupational Therapy and Rehabilitation, 11(3), 199201.
Baltimore: Mosby. Dunton, W. R. (1915). Occupational therapy: A manual for
Bair, J. (1982). Nationally speaking: Changing trends in prac- nurses. Philadelphia: W. B. Saunders.
tice. American Journal of Occupational Therapy, 36(11), Dunton, W. R. (1954). History and development of occupa-
70407. tional therapy. In H. S. Willard & C. S. Spackman (Eds.),
Barton, I. (1968). Consolation house, fifty years ago. American Principles of occupational therapy (2d ed., pp. 110).
Journal of Occupational Therapy, 22(4), 34045. Philadelphia: Lippincott.
Barunga, A. (1975). Sacred sites and their protection. In Edwards, R. (Ed.). (1975). The preservation of Australias
R. Edwards (Ed.), The preservation of Australias aborigi- aboriginal heritage. Canberra: Australian Institute of
nal heritage (pp. 7576). Canberra: Australian Institute Aboriginal Studies.
of Aboriginal Studies. Fay, E. V., & Kellogg, I. M. (1954). Occupational therapy in
Baum, C. M., & Law, M. (1997). Occupational therapy prac- general and surgical hospitals. In H. S. Willard & C. S.
tice: Focusing on occupational performance. American Spackman (Eds.), Principles of occupational therapy (2d
Journal of Occupational Therapy, 51(4), 27788. ed., pp. 11737). Philadelphia: Lippincott.
Bowden, R., & Bunbury, B. (1990). Being aboriginal: Com- Finn, G. (1972). The occupational therapist in prevention pro-
ments, observations and stories from aboriginal grams. American Journal of Occupational Therapy, 26(2),
Australians. Crows Nest, New South Wales: Australian 5966.
Broadcasting Corporation Enterprises. Finn, G. (1977). Update of Eleanor Clarke Slagle Lecture: The
Brachtesende, A. (2004, October 20). Centennial Vision moves occupational therapist in prevention programs. American
forward. AOTA Newsroom. Journal of Occupational Therapy, 31(10), 65859.
1193_Ch01_001-021.qxd 6/8/09 5:30 PM Page 19

Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 19

Frenz, H. (ed.). (1969). Nobel lectures, literature 19011967. Licht, S. (1948). Early history of occupational therapy. In
Amsterdam: Elsevier. S. Licht (Ed.), Occupational therapy sourcebook (pp. 117).
Friedland, J. (1998). Looking backOccupational therapy and Baltimore: Williams and Wilkins.
rehabilitation: An awkward alliance. American Journal of Licht, S. (1967). The founding and the founders of the American
Occupational Therapy, 52(5), 37380. Occupational Therapy Association. American Journal of
George, N. M., Braun, B. A., & Walker, J. M. (1982). A pre- Occupational Therapy, 21(5), 26977.
vention and early intervention mental health program for Lyons, A., & Petrucelli, R. (1987). Medicine: An illustrated
disadvantaged pre-school children. American Journal of history. New York: Abradale Press.
Occupational Therapy, 36(2), 99106. MacDonald, E. M. (Ed.). (1976). Occupational therapy in
Gleave, G. M. (1954). Occupational therapy in childrens rehabilitation: A handbook for occupational therapists,
hospitals and pediatric services. In H. S. Willard & C. S. students and others interested in this aspect of reablement
Spackman (Eds.), Principles of occupational therapy (4th ed.). Baltimore: Williams & Wilkins.
(2d ed., pp. 13867). Philadelphia: Lippincott. Mandel, D. R., Jackson, J. M., Nelson, L., & Clark, F. A. (1999).
Gourley, M. (2000, May 8). Center for occupational therapy Lifestyle redesign: Implementing the well elderly program.
and lifestyle redesign. OT Practice, 5(10), 1819. Bethesda, MD: American Occupational Therapy Association.
Gourley, M. (2001a, August 20). News: AOTA Updates: AOTA McDaniel, M. L. (1968). Occupational therapists before World
teams with L.L. Bean. OT Practice, 6(15), 3. War II (191740). In H. S. Lee & M. L. McDaniel (Eds.),
Gourley, M. (2001b, September 17). News: AOTA Updates: Army Medical Specialist Corps (pp. 6997). Washington,
AOTA Spearheads backpack initiative. OT Practice, 5(10), 3. DC: Office of the Surgeon General, Department of the
Army. Retrieved December 4, 2005, from http://history
Green, M. C., Lertvilai, M., & Bribrieso, K. (2001). Prospering .amedd.army.mil/booksdocs/histories/ArmyMedical
through change: CAOT from 1991 to 2001. Occupational SpecialistCorps/chapter4.htm.
Therapy Now, 3(6) [online version]. Retrieved December 4,
2005, from http://www.caot.ca/otnow/nov01-eng/nov01.cfm. National Library of Medicine. (2004a). Greek medicine:
Asclepius. Retrieved December 14, 2004, from http://
Hasselkus, B. R. (2004). Eleanor Clarke Slagle LectureThe www.nlm.nih.gov/hmd/greek/greek_asclepius.html.
world of everyday occupation: Real people, real lives.
American Journal of Occupational Therapy, 60, 62740. National Library of Medicine. (2004b). Greek medicine:
Pythagoras. Retrieved December 4, 2004, from http://
Jaffe, E. (1986). Nationally speakingThe role of occupa- www.nlm.nih.gov/hmd/greek/greek_pythagoras.html.
tional therapy in the disease prevention and health promo-
tion. American Journal of Occupational Therapy, 40(11), National Library of Medicine. (2004c). Shell shock. Retrieved
74952. December 5, 2004, from http://www.nlm.nih.gov/news/
Johnson, J. A. (1986a). Wellness: A context for living. Thorofare,
NJ: SLACK. National Library of Medicine. (2005). Untitled document. Re-
trieved February 24, 2005, from http://www.nlm.nih.gov/
Johnson, J. A. (1986b). Wellness and occupational therapy. hmd/breath/breath_exhibit/FourPersp/sick/IVDb1.html.
American Journal of Occupational Therapy, 40(11),
75358. National Museum of American Indians. (2005). Our universes:
Traditional knowledge shapes our world. Retrieved February
Kavasch, E. B., & Baar, K. (1999). American Indian healing 24, 2005, from http://www.nmai.si.edu/subpage.cfm?
arts. New York: Bantam Books. subpage=dc&second=visitor&third=inside#universes.
Keegan, J. (2003). Leaders and revolutionaries: Winston Churchill. Neuhas, B. (1968). Founders Day at Clifton Springs. American
Time 100: The most important people of the century. Retrieved Journal of Occupational Therapy, 22(4), 33739.
December 6, 2005, from http://www.time.com/time/time100/
leaders/profile/churchill4.html. Parush, S., Lapidot, G., Edelstein, P. V., & Tamir, D. (1987).
Occupational therapy in mother and child health care cen-
Kirchman, M. M., Reichenbach, V., & Giambalvo, B. (1982). ters. American Journal of Occupational Therapy, 41(9),
Preventative activities and services for the well elderly. 60105.
American Journal of Occupational Therapy, 36(4), 23642.
Peloquin, S. M. (1991a). Looking backOccupational therapy:
Krieger, D. (2001, Winter). Something old, something new. Individual and collective understandings of the founders, Part 1.
USC Trojan Family Magazine. Retrieved January 2, 2005, American Journal of Occupational Therapy, 45, 35260.
from http://www.usc.edu/dept/pubrel/trojan_family/
winter01/therapy/something.html. Peloquin, S. M. (1991b). Looking backOccupational therapy:
Individual and collective understandings of the founders, Part 2.
Kronenberg, F., Algado, S. S., & Pollard, N. (Eds.). (2005). American Journal of Occupational Therapy, 45, 73344.
Occupational therapy without borders: Learning from the
spirit of survivors. New York: Elsevier, Churchill Livingstone. Peterson, N. (1975). The ownership of sacred sites. In R. Edwards
(Ed.), The preservation of Australias aboriginal heritage
Lasker, R. D., & the Committee on Medicine and Public (pp. 7375). Canberra: Australian Institute of Aboriginal
Health. (1997). Medicine & public health: The power Studies.
of collaboration. New York: The New York Academy
of Medicine. Pizzi, M., Scaffa, M., & Reitz, S. M. (2006). Health promotion
and wellness for people with physical disabilities. In
Levin, H. L. (1937). Occupational and recreational therapy H. M. Pendleton & W. Schultz-Krohn (Eds.), Pedrettis
among the ancients. Occupational Therapy and Rehabilita- occupational therapy for physical dysfunction (6th ed.,
tion, 17(5), 31116. pp. 6578). St. Louis, MO: Elsevier.
1193_Ch01_001-021.qxd 6/8/09 5:30 PM Page 20

20 SECTION I Foundations and Key Concepts

Punwar, A. J. (2000). The development of occupational ther- Townsend, E. (1999). Invited comment: Enabling occupation in
apy. In A. J. Punwar & S. M. Peloquin (Eds.), Occupational the 21st century: Making good intentions a reality. Australian
therapy: Principles and practice (3d ed.). Baltimore: Occupational Therapy Journal, 46, 14759.
Lippincott Williams & Wilkins. United Service Organizations (USO). (2005). Historical time-
Reilly, M. (1962). Occupational therapy can be one of the line. Retrieved February 26, 2005, from http://www.uso.org/
great ideas of 20th century medicine. American Journal of pubs/8_14_34.cfm.
Occupational Therapy, 16(1), 19. University of Southern California (USC), Department of
Reitz, S. (1984, April). Preventive health: An essential compo- Occupational Science and Occupational Therapy. (2004).
nent of occupational therapy. Presentation at American Occu- About us: Center for Occupation and Lifestyle Redesign.
pational Therapy Association Conference, Kansas City, MO. Retrieved January 2, 2005, from http://www.usc.edu/
Reitz, S. M. (1990). The historical and philosophical bases for schools/ihp/ot/about/center/.
occupational therapys role in health promotion. Presenta- University of Texas Medical Branch, Academic Resources.
tion at the 10th International Congress of the World Federa- (2005). Aulus Cornelius Celsus. [Lithograph]. Retrieved
tion of Occupational Therapists, Melbourne, Australia. February 24, 2005, from http://ar.utmb.edu/areas/
Reitz, S. M. (1992). A historical review of occupational ther- informresources/collections/blocker/portraits/bios/celsus.asp.
apys role in preventive health and wellness. American U.S. Department of Health and Human Services. (1990).
Journal of Occupational Therapy, 46, 5055. Healthy People 2000: National health promotion and
Reitz, S. M. (2004). Health and wellness through: Occupation: disease prevention objectives. Washington, DC: Govern-
The American Perspective invited Open Seminar, Hospital ment Printing Office.
Authority, Hong Kong. U.S. Department of Health and Human Services. (1999).
Savage-Smith, E. (1994). Islamic culture and the medical arts: Mental health: A report of the Surgeon General.
An exhibit at the National Library of Medicine. Bethesda, Rockville, MD: Author.
MD: National Library of Medicine [online brochure]. Re- U.S. Department of Health and Human Services. (2000).
trieved December 4, 2004, from http://www.nlm.nih.gov/ Healthy People 2010: Understanding and improving health
exhibition/islamic_medical/islamic_00.html. (2d ed). Washington, DC: U.S. Government
Scaffa, M. E. (2001). Community-based practice: Occupation Printing Office.
in context. In M. E. Scaffa (Ed.), Occupational therapy in Vogel, V. J. (1970). American Indian medicine. University of
community-based practice settings (pp. 318). Philadelphia: Oklahoma: University of Oklahoma Press, Norman
F. A. Davis. and London.
Scaffa, M. E., & Brownson, C. (2005). Occupational therapy West, W. (1967). The occupational therapists changing respon-
interventions: Community health approaches. In C. H. sibility to the community. American Journal of Occupa-
Christiansen, C. M. Baum, & J. Bass-Haugen (Eds.), tional Therapy, 21(5), 31216.
Occupational therapy: Performance, participation and West, W. (1969). The growing importance of prevention.
well-being (3d ed., pp. 47788). Thorofare, NJ: SLACK. American Journal of Occupational Therapy, 23(3), 22631.
Scaffa, M. E., Van Slyke, N., Brownson, C. A., & American Wiemer, R. (1972). Some concepts of prevention as an aspect
Occupational Therapy Association Commission on Practice. of community health. American Journal of Occupational
(2008). Occupational therapy services in the promotion of Therapy, 26(1), 19.
health and the prevention of disease and disability, American
Journal of Occupational Therapy 62(6), 694703. Wiemer, R. (1979). Traditional and nontraditional arenas.
In Occupational therapy: 2001 AD (pp. 4253). Rockville,
Schwartz, R. K. (1989). Cognition and learning in industrial MD: Author.
accident injury prevention: An occupational therapy per-
spective. Occupational Therapy in Health Care, 6(1) 6785. Wilcock, A. A. (1998). An occupational perspective of health.
Thorofare, NJ: SLACK.
Shaffer, G. W. (1938). Recreation as a preventive and therapy
for social maladjustments. Occupational Therapy and Wilcock, A. A. (2000). Development of a personal, professional
Rehabilitation, 17(2), 97106. and educational philosophy: An Australian perspective.
Occupational Therapy International, 7(2), 7986.
Sivin, N. (1995). State, cosmos, and body in the last three cen-
turies B.C. Harvard Journal of Asian Studies, 55(1), 537. Wilcock, A. A., & Townsend, E. (2000). Occupational termi-
nology interactive dialogue: Occupational justice. Journal
Soames, M. (2002). Foreword. In W. Churchill, Painting as a of Occupational Science, 7(2), 8486.
pastime (pp. viiviii). Delray, FL: Levinger.
Willard, H., & Cox, B. (1979). A profile of occupational ther-
Spear, P. S., & Crepeau, E. B. (2003). Glossary. In E. B. Crepeau, apy and occupational therapy practice. In Occupational
E. S. Cohn, & B. A. Schell, Willard & Spackmans occupa- Therapy: 2001 (pp. 6970). [An interview of H. Willard by
tional therapy (10th ed., pp. 102535). Philadelphia: B. Cox]. Rockville, MD: American Occupational
Lippincott, Williams & Wilkins. Therapy Association.
Stallings-Sahler, S. (2007). AOTAs Statement on stress and Willard, H., & Spackman, C. (1971). Occupational therapy
stress disorders. American Journal of Occupational (4th ed., p. 1). Philadelphia: Lippincott.
Therapy, 61, 711.
World Health Organization. (1947). Constitution of the World
Stattel, F. M. (1977). Occupational therapy: Sense of the past Health Organization. Chronicle of the World Health
Focus on the present. American Journal of Occupational Organization, 1(1), 2940.
Therapy, 31, 64950.
1193_Ch01_001-021.qxd 6/8/09 5:30 PM Page 21

Chapter 1 Historical and Philosophical Perspectives of Occupational Therapys Role in Health Promotion 21

World Health Organization (WHO). (2001). The international Zemke, R. (2004). The 2004 Eleanor Clarke Slagle Lecture
classification of functioning, disability, and health (ICF). Time, space, and the kaleidoscopes of occupation. American
Geneva, Switzerland: Author. Journal of Occupational Therapy, 58, 60820.
Wudang Taoist Internal Alchemy. (2005). Mount Lao Shan and
the temples. Retrieved December 4, 2005, from
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Chapter 2

Occupational Therapy Conceptual

Models for Health Promotion Practice
S. Maggie Reitz, Marjorie E. Scaffa, and Michael A. Pizzi

Science is facts; just as houses are made of stones, so is science made of facts; but a pile
of stones is not a house and a collection of facts is not necessarily science.
Henri Poincare (18541912)

Learning Objectives
This chapter is designed to enable the reader to:
Describe a variety of models from within the pro- 2008]) and the World Health Organizations
fession of occupational therapy that could possi- (WHO) International Classification of Functioning,
bly support health promotion programs. Disability and Health (ICF [WHO, 2001]) with
Evaluate the advantages and disadvantages the application of a theory or conceptual
of the various models for use in occupational practice model.
therapy health promotion interventions in Select appropriate models that support occupa-
different contexts. tional therapy health promotion intervention tar-
Integrate language of the American Occupational geted to a specific population, health problem, or
Therapy Associations (AOTA) Occupational Ther- incidence of occupational apartheid.
apy Practice Framework (Framework [AOTA,

K e y Te r m s
Environment Input Occupational identity Throughput
Environmental fit Interests Output Values
Feedback Occupational adaptation Performance capacity Volition
Habituation Occupational apartheid Personal causation
Health promotion Occupational Primary energy
Human agency competence Secondary energy

Introduction The authors believe the selected occupational ther-

Theorists organize the building blocks of science apy models are sufficiently broad to apply to the
constructs and principlesinto an organized pattern, variety of populations and health behaviors addressed
or theory, that explains natural events. This theory con- in this text. In addition, they are particularly well suited
struction can be guided by philosophical assumptions for use in combination with selected models from other
as depicted in Figure 2-1. The theories used by occu- health disciplines. Examples of models from related
pational therapists explain and predict human behavior disciplines are presented in Chapter 3 of this text,
in relation to health and occupational performance. which also provides guidance for selecting and possi-
This chapter reviews a selection of theories and mod- bly combining occupational therapy models and those
els from occupational therapy to provide a framework from other disciplines to enhance theoretical support
for health promotion practice. for health promotion programs.
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 23

2005b, 2006a; Iwama, Odawara, & Asaba, 2006; Lim

Philosophical Assumptions & Iwama, 2006).
Humans are occupational creatures who cannot be Prior to discussing the models, terminology used to
healthy in the absence of meaningful occupation describe the components of theory is reviewed to aid in
Assumption from the Model of Human Occupation the description of each model. In addition, schematics
(Scott, Miller, & Walker, 2004, p. 288) and health promotion practice examples are provided
for each model. Through an understanding of the pro-
fessions philosophy and theories, interventions can be
Concepts/Constructs optimally designed. These interventions can facilitate
the efforts of individuals, families, and communities as
Environment Development Performance they seek to improve their health, their participation in
society, and their overall quality of life through engage-
Health Strength Human Person ment in occupation.

Occupation Participation Well-Being

Importance of Theory
to Health Promotion Practice
Models and theories provide the foundational context
Ecology, or the interaction between person and for program design, implementation, and evaluation
the environment, affects human behavior and (Scaffa, 1992). However, research and theory have lit-
performance, and that performance cannot be
tle to offer society unless they are applied and used
understood out of context
Postulate from The Ecology of Human Performance (Royeen, 2000, p. v). When used, both occupational
(Dunn, Brown, & McGuigan, 1994, p. 598) therapy theories and those from related disciplines can
enhance the design and evaluation of health promotion
programming. Thus, it is important for occupational
Theory/Framework/Model therapists to be knowledgeable of and proficient in the
use of models and theories. Many reasons exist for the
Figure 2-1 Theory construction process.
limited use of theory in practice (Reitz, 1998a), includ-
Developed by S. Maggie Reitz.
ing the ever-increasing pace of change, the demands
placed on health-care workers that impact the art of
practice (Peloquin, 1989), and the lack of available
Many occupational therapy models exist that may time to explore theoretical ideas in practice (Reitz,
be combined or used independently to support efforts 1998a). Occupational therapists and occupational ther-
in community-based health promotion interventions. apy assistants are not immune from significant time
Readers are encouraged to examine the literature pressures in their work and personal lives. These pres-
for additional modelsthose developed within the sures decrease the available time to be a competent
United States and those developed in other countries consumer of available research and theory. Skills
to find the model that best fits the community or in time management and priority setting must be honed
health behavior of interest. This chapter reviews to acquire sufficient time to engage in theory and evi-
five recognized and widely used models, including dence-based practice. In addition, the use of technol-
the following: ogy and such resources as OTseeker (Bennett et al.,
2003) save the occupational therapist and occupational
Ecology of Human Performance (EHP) Framework
therapy assistant time and facilitate competent, evidence-
Model of Human Occupation (MOHO)
based practice supported by theory.
Occupational Adaptation (OA) Theory
Additional challenges hinder proficiency in the
Person-Environment-Occupation (PEO) Model
application of theory. Few occupational therapists and
occupational therapy assistants have had the opportu-
(PEOP) Model
nity to observe theory application during their field-
In addition, the chapter also describes a newer work experiences. In addition, little emphasis is placed
model that is growing in popularity and has the poten- on theory in continuing-education courses. The use of
tial to contribute to health promotion initiatives. Devel- inconsistent and sometimes conflicting terminology
oped from an Asian perspective, this model is known as can create initial confusion and can lead to subsequent
the Kawa (river in Japanese) Model (Iwama, 2005a, theory avoidance. However, many important reasons
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24 SECTION I Foundations and Key Concepts

exist for bridging the gap between theory and practice. and systems into broader schemas that explain how the
Miller and Schwartz (2004) identified five reasons to profession makes, uses, and discards ideas about people
be knowledgeable of and competent in the use of the- and their occupations. Reviewing Figure 2-1 will assist
ory (see Content Box 2-1). All five of these reasons are the reader in understanding this theory construction
consistent with the AOTA Occupational Therapy Code process.
of Ethics (AOTA, 2005), specifically Principle 4, which Knowledge can be organized into systems in order
addresses duties and states occupational therapy per- to facilitate discussion of ideas and foster develop-
sonnel shall achieve and continually maintain high ment of theories. These systems seek to explain the
standards of competence (p. 3). relationships between philosophy, theory, practice,
It is imperative that occupational therapy students and research and have been visualized and described
and occupational therapists feel comfortable when in different ways. Disciplines organize knowledge for
articulating the theory base of occupational therapy practical use into theories and models, and, within
and when applying theory, from both occupational occupational therapy, frames of reference. These
therapy and other related disciplines to intervention organizational structures can be viewed as parts of
and program planning. When doing so, they blend the larger, more complex organizational systems that con-
art of a caring practice (Peloquin, 1989, 2005) with tain and support the knowledge used by a profession
the science of the discipline, which is supported by (Reitz & Scaffa, 2001).
the occupational therapy professions core values of Many schematics exist that visually represent dif-
justice, dignity, truth, and prudence (AOTA, 1993). ferent methods of organizing occupational therapy
The next section reviews terminology, the relationship knowledge. Two of these methods are included for
between philosophy, theory, practice, and research to review and consideration; in one, Kielhofner employs
foster artful scientific practice. a series of concentric circles (Fig. 2-2), while in the
other, Reitz uses a comet metaphor (Fig. 2-3). These
organizational schemes can be helpful tools in the
Terminology and Relationships study of occupational therapy knowledge. The links
Between Philosophy, Theory, between the science of occupation and health, both
within and external to the profession, and the links
Practice, and Research between theory and practice are delineated. There are
The terminology used in the discussion of theory is similarities and differences in the way these links are
complex and often used in conflicting ways by theorists displayed in the two schematics.
and writers (Miller & Schwartz, 2004). Table 2-1 was For example, in Figure 2-2, the paradigm is located in
developed to help decrease confusion in this area. Fre- the center and represents Kielhofners view that it most
quently used terms, including paradigm, frame of refer- directly addresses the identity and outlook of the field
ence/conceptual model of practice, postulate/principle, (Kielhofner, 2004, p. 15). In Figure 2-3 Reitz (1998b,
concept/construct, and philosophical assumptions are 2000) provides an alternate representation, which
defined within this table. With an understanding of the includes the recipient of care. In this view, the recipient
stones that build theories and of the building blocks of of services appears at the comets core in order to
knowledge, the reader is ready to organize these ideas emphasize the importance of client-centered care. The
service recipient can be an individual, family, commu-
nity, or population. The paradigm is depicted as the
comets body and uses the symbolism of the comet mov-
Content Box 2-1 ing through space and time to represent how the profes-
sions past influences its current viewpoint and how the
Reasons for Advocating Knowledge current view impacts its future trajectory. Occupational
and Competency in Theory science is not included in Kielhofners schematic. In the
To validate and guide practice comet metaphor, Reitz portrays occupational science as
To justify reimbursement an attractor and mediator of knowledge from other disci-
To clarify specialization items plines that can support the theoretical basis of occupa-
To enhance the growth of the profession
and the professionalism of its members
tional therapy practice. This view is consistent with the
To educate competent practitioners description of occupational science as a human science
that is concerned with the systematic study of the form,
Content from What is theory, and why does it matter? by R. J. Miller function, and meaning of human occupation in all con-
and K. Schwartz, 2004, in K. F. Walker and F. M. Ludwig (Eds.), Per-
spectives on theory for the practice of occupational therapy (3d ed., texts, including the therapeutic context (Clark, as cited
pp. 126). Austin, TX: Pro-ED. in Crist, Royeen, & Schkade, 2000, p. 49).
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Table 21 Common Theoretical Terms and Definitions

Term Definition Definition Example(s)

Paradigm Compilation of a unique Typical way in which an Figures 2-2 and 2-3
set of shared ideas, val- academic discipline defines
ues, and beliefs about a its current theoretical sys-
discipline, which create tem, field of study, meth-
the foundation and vision ods of research, and stan-
of the profession (Kiel- dards for acceptable
hofner, 2004 based on solutions at any given time
the work of Kuhn, 1970). (Mosey, 1981, p. 123).
Frame of Reference/ Fundamental components Presents and organizes Sensory Integration (Miller
Conceptual Practice of practice consisting of theory used by therapists & Schwartz, 2004)
Model beliefs and scientific theo- in their work . . . Model of Human
ries that are thought to be addresses some specific Occupation
expert opinions in a disci- phenomena or area of (Kielhofner, 2004)
pline. Professions consist human function (Kielhofner,
of one model and many 2004, p. 20). Conceptual
frames of reference which practice models give justi-
are more limited and fication for specific prac-
focused on one particular tice methods and provide
aspect of the professions therapists with a way to
theory. Frames of refer- understand clients unique
ence include concepts, perspectives, occupations,
terms, and postulates experiences, and prob-
that are related to specific lems (Kielhofner, 2004).
areas of practice (Mosey,
Principle/Postulate Postulates describe rela- Principles describe the Figure 2-1
tionships between two relationship between phe-
or more concepts nomena of interest (i.e.,
(Mosey, 1981, p. 36). concepts/constructs).
Concept/Construct Concepts are observable Concepts identify struc- Figure 2-1
characteristics of the en- tural features or objects
vironment; constructs are (e.g., table, chair); con-
intangible characteristics structs characterize
(Mosey, 1981). observations (e.g.,
patience, wellbeing).
Philosophical Assumptions Basic beliefs about the Beliefs that are the Man is . . . an organism
nature of human life, the essence of a culture, soci- that maintains and balances
individual, society, the ety, discipline, or move- itself in the world of reality
universe, and the rela- ment and which support and actuality by being in
tionships among these its decision-making. active life and active use,
various phenomena i.e., using and living and
(Mosey, 1981, p. 17). acting its time in harmony
with its own nature and
the nature about it
(Meyer, 1922/1977, p. 641).
Man through the use of his
hands as they are energized
by mind and will, can influ-
ence the state of his own
health (Reilly, 1962, p. 2).

Developed by S. Maggie Reitz.

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26 SECTION I Foundations and Key Concepts

lated ge Comet Analogy Explained

l Practice OT Theories
tua Mo

nc Paradigm



Frames of Non OT Theories

Conceptual Recipient
Models of
Figure 2-2 Kielhofners view of the relationship between re- Figure 2-3 Reitzs view of the relationship between paradigm,
lated knowledge, conceptual practice models, and paradigms. occupational science, theories, and conceptual models of prac-
From Conceptual foundations of occupational therapy (3d ed., p. 15), by tice and the recipient of the intervention.
G. Kielhofner, 2004, Philadelphia: F. A. Davis. Copyright 2004 by F. A. Davis. Reproduced and adapted from S. M. Reitz in Theoretical frameworks for
Reprinted with permission. community-based practice (p. 59) by S. M. Reitz & M. Scaffa in Occupational
therapy in community-based practice settings, M. Scaffa (Ed.), 2001, Philadel-
phia: F. A. Davis. Copyright 2001 by F. A. Davis. Reprinted with permission.
Occupational Therapy
Theories/Models An overview of the basic assumptions and con-
As stated above, a sampling of the occupational ther- structs of each model will be presented. This overview
apy theories and models available for use in health pro- is followed by a discussion of the models applicability
motion will be described in this chapter. Determining to health promotion and an example of a theory-based
which theories to include was a challenging task, with health promotion intervention. Theorists responses to
selection based on potential for use in support of one or more questions posed by the authors during the
health promotion programming. The reader is encour- preparation of this chapter appear either embedded in
aged to reflect on how the presented models may be the text or as Content Boxes. The amount of discussion
used in health promotion and to use these and other varies slightly based on the complexity of the theory or
models in day-to-day practice. Of primary importance, example. Prior to using any of these models in health-
however, is the application of the theory that best promotion practice, the reader is strongly encouraged
matches the population or context, rather than trying to to read the most recent literature both on testing of the
fit the population or program to a specific model. particular model and on evidenced-based research that
Although the presentation order was chosen solely applies the model.
on placing the selected models in alphabetical order,
Ecology of Human Performance (EHP):
this sequence also has a logical flow.
Ecology of Human Performance (EHP) Framework The impetus for the development of this framework
Model of Human Occupation (MOHO) by the faculty at the University of Kansas was to
Occupational Adaptation (OA) Theory express the complexity of context and its impact on oc-
Person-Environment-Occupation (PEO) Model cupational engagement. The development of the frame-
Person-Environment-Occupation-Performance work was influenced by the work of environmental and
(PEOP) Model developmental psychologists, as well as occupational
The discussion starts with two of the disciplines first therapy theorists and occupational scientists (Dunn,
models to examine the human and environment Brown, & McGuigan, 1994). The primary assumptions
interactionthe EHP Framework and the MOHO. include the following:
These models are followed by the OA theory (Schultz To understand the occupational performance of hu-
& Schkade, 2003), which focuses on the internal process mans, and that performance must be studied in con-
of adaptation to maximize health and participation. The text (Dunn, McClain, Brown, & Youngstrom, 2003)
discussion ends with two models having similar termi- People and their contexts are unique and dynamic
nology and primary constructs, the PEO and the PEOP. (Dunn et al., 2003, p. 224)
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 27

Contrived contexts are different from natural of individuals but increasingly also in families.
contexts (Dunn et al., 2003, p. 224) This type of intervention also could be used at
the community level.
The major constructs of this conceptual practice
2. At the Adapt level, the therapist adapts the con-
modelthe person and his or her skills, abilities, per-
textual features and task demands to support per-
formance range, context, and habitual tasksare dis-
formance (Dunn et al., 1994, p. 604), again this
played in Figure 2-4. Individuals skills and abilities in
could be used with an individual or family in
combination with a perception of their context support
their contexts or a community.
the selection and performance of specific tasks, which
3. At the Alter level, the therapist changes the actual
are defined in the model as objective sets of behaviors
context rather than adapting the current one. An
necessary to accomplish a goal (Dunn et al., 1994,
example of such an intervention would be facilitat-
p. 599). The performance range of each individual,
ing the move of an individual who had a series of
family, or community depends on both past experience
falls in severe winter weather to a retirement com-
and current resources. Limited access to resources may
munity that has covered walkways so the individ-
impact the performance range of an individual, family,
ual will not be forced to walk outside. She can use
community, or population, even if they have a wide
the covered walkways to engage in occupations
repertoire of skills and abilities.
that she enjoys (e.g., having meals with friends)
These diminished resources may be due to a tempo-
and other activities of daily living (ADLs) and
rary crisis or a more permanent situation. For example, a
instrumental activities of daily living (IADLs)
well-functioning community in the Sunbelt may find
such as mail retrieval.
their ability to respond to an emergency (i.e., perfor-
4. The Prevent level of intervention seeks to
mance range) significantly hindered temporarily by a rare
prevent the occurrence or evolution of maladap-
snowfall. If the same community was to experience three
tive performance in context (Dunn et al., 1994,
back-to-back hurricanes in successive hurricane seasons,
p. 604). This type of intervention could be at the
resources and skills would need to be addressed, or the
individual, family, or community level.
performance range of the community would narrow and
5. At the Create level, the goal is to create circum-
remain constrained through the hurricane season. This
stances that promote more adaptable or complex
situation would impact the productivity and quality of life
performance in context (Dunn et al., 1994, p.
of the individuals and the community as a whole.
604). Policy initiatives, program development,
The EHP model provides five alternatives for ther-
community development, and community
apeutic intervention (Dunn et al., 1994, p. 603):
empowerment are all activities at this level
1. The Establish/Restore level includes traditional of intervention and are examples of health-
interventions that seek to restore function via the promotion activities.
improvement of skills and abilities, most often
In the EHP framework, intervention is always
guided by the cultural context of the individual, fam-
ily, community, or population. Tasks that an individ-
Text/Image rights not available. ual, family, community, or population pursue are
influenced by skills and abilities and by personal
choices, priorities, and values that are often guided
by both life experience and culture. For example, a
communitys decision to adapt a playground to ensure
it is accessible may be initiated by the work of one
young (e.g., middle school) advocate with a younger
disabled sibling.
Ecology of Human Performance:
Applicability in Health Promotion
The relationship of the EHP to the promotion of
health and wellbeing is presented in Content Box 2-2.
The EHP has been identified as an appropriate frame-
work for health promotion, as described below:
Interventions are intended to assist individuals in
recognizing their health needs, acting, and gaining
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28 SECTION I Foundations and Key Concepts

competence in the performance of these behaviors. Two lack of knowledge as a primary barrier versus lack of
of the EHPs intervention alternatives relate directly to ability skill. Examining the potential barriers to quality
preventive health behaviors. The Prevent and Create of life is important to consider in health promotion
alternatives address how therapists assess an individuals intervention and program planning. Understanding
context and take steps to avoid the occurrence of nega- the potential differences between and among commu-
tive outcomes, or formulate a new set of circumstances nity, group, family members, and service providers
to encourage the individuals success. (Lutz, 1998, p. 17) is important in order to maximize the interventions
overall success.
These levels of intervention can be easily matched
While a solid base of published research has not
to levels of prevention and health promotion. An inter-
substantiated the EHP model, it shows promise for use
vention at the Prevent level may, for example, include
in health promotion programs directed at groups, fam-
the development of an interdisciplinary program to ed-
ilies, communities, or populations. For example, the
ucate first-year college students about healthy eating
EHP could be used to both structure a transition pro-
and cooking techniques that match their limited space
gram within the criminal justice system and to set a
and available funds. This program would address both
direction for developing measurable outcome objec-
the prevention of weight gain and the enhancement of
tives for the programs evaluation. As with the Model
the students performance range. Forming a commu-
of Human Occupation (MOHO), the EHPs interdisci-
nity group to advocate for a walking trail that would
plinary theoretical foundation makes it well suited for
also be accessible to wheelchair users to promote phys-
use in interdisciplinary health promotion programs
ical activity, leisure engagement, and a healthy lifestyle
with populations or communities. This model has been
is an example of a Create-level intervention.
used in conjunction with a health behavior model,
Limited EHP-related research is presently available.
specifically the Health Belief Model, to design an inter-
In one of the few existing studies, Brown, Cosgrove,
disciplinary health promotion program. The Strides for
and DeSelm (1997) used the EHP to examine barriers
Life walking program for older adults was conducted at
to recovery and quality of life for clients with severe
a nutrition site in western Maryland (Stevenson, 1998)
and persistent mental illness. Barriers were identified
and was supported by a Health Resources and Services
through the lenses of clients and their case managers.
Administration grant (Grant #36 AH 10043-4). The
The EHP was used to classify these barriers as relating
decision-making or matching process of selecting
to person or context. The study included 33 participants
two complementary models will be described in the
(20 clients and 13 case managers; some case managers
next chapter.
were assigned to more than one participant). Results in-
dicated that clients identified more contextual barriers Ecology of Human Performance:
while case managers most frequently identified barriers Health Promotion Example
related to the person and their skills. Clients identified
Cindy is unknowingly used by her boyfriend to drive a
getaway car after he steals a large amount of illicit
drugs from an undercover police officer. After the
Content Box 2-2 boyfriend fires shots, they are both apprehended. She is
Dr. Winnie Dunns Reflections sent to a womens detention center, since she has insuf-
ficient funds to post bail. Her family, who had previ-
on the EHP ously expressed concern about the boyfriend and his
Question: habits, refuses to assist with bail. She feels betrayed by
From your perspective, how do you see the EHP her boyfriend, abandoned by her family, and unsure
relating to the health and wellbeing of people? about her future. Prior to her arrest, she had hoped to
Response: attend the local community college to study informa-
One of our favorite things about the EHP framework tion technology.
is that it is NOT about disability, disease, or other Cindy requests and secures placement in a transition
problem focused issues . . . It is about living, how program for women at the detention center. This pro-
ALL of us live and thrive . . . All of us are negotiating grams overarching goal is to decrease violence within
the task, context and our own skills to conduct our the detention center through a comprehensive stress-
daily lives, and the EHP merely illustrates these rela-
tionships. It levels the playing field, with no one reduction initiative. The agreement includes a com-
standing out as the problem. . . . We could mitment to participate in an 8-week group-structured
plot anyones life on the diagram, and all of us have interdisciplinary program. Occupational therapy is
challenges and successes in the interaction of task part of this program, together with yoga, physical
context and our own skills. activity, health education, and other activities. The
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 29

occupational therapy portion of the program is devel- Content Box 2-3

oped and delivered jointly by an occupational therapy
graduate student and an occupational therapy faculty Human Order Principles That Support
member who is also a trained health educator. This the MOHO
portion of the program focuses on a combination of
Humans are composed of flexible elements
self-assessment, occupational engagement, and educa- whose interaction with each other and with the
tion focused on the domain of occupational therapy environment depends on the situation.
(AOTA, 2008). Thinking, feeling, and doing emerge out of dy-
Sessions are held weekly for 1 hour (Dailey & Reitz, namic interactions between elements within the
2003). At the first session, each woman completes a self- person and those in the environment.
Dysfunction is the result of the interaction of con-
assessment of occupational needs to determine which ditions internal and external to the person.
performance skills and patterns could be strengthened Function can be enhanced through remediation of
for enhanced ADL and IADL participation. Based on a faulty element, compensation by another ele-
trends in the groups needs, the occupations and educa- ment within the person, and/or by environmental
tion units provided over the next 7 weeks are adjusted. modification.
The women participate in a variety of occupations Content from A model of human occupation: Theory and application
designed to facilitate an increase in their performance (3d ed., p. 38), by G. Kielhofner, 2002, Baltimore: Lippincott, Williams
& Wilkins. Copyright 2002 by Lippincott, Williams & Wilkins.
range. Their performance ranges are increased by either
remediating or enhancing skills through such activities
as rsum writing, job interviewing, healthy low-cost
leisure pursuits, parenting skills, and basic health aware- learn, and sustain performance patterns; and how the
ness and self-screening skills. Each session concludes environment impacts that performance. The importance
with a discussion of how the days activities would of the environments relationship to occupational per-
enhance role performance and the womens overall formance is a major focus (University of Illinois at
health and wellbeing. Chicago [UIC], 2005a). The MOHO emphasizes that
through therapy, persons are helped to engage in doing
Model of Human Occupation (MOHO): things that maintain, restore, reorganize, or develop
Overview their capacities, motives, and lifestyles.
From its inception, the MOHO was influenced by Reillys The primary original constructs of the MOHO include
work on occupational behavior (1962, 1969, 1974) and feedback, input, throughput, and output. These constructs
theories from other disciplines (Kielhofner, 1985a, 2004). are linked in a cycle that describes how humans interact
This interdisciplinary base (Kielhofner, 2004) included the- with the environment (Kielhofner, 1980a, 1980b; Kiel-
ories from anthropology; sociology; psychology, including hofner & Burke, 1980; Kielhofner & Igi, 1980). This
environmental and social psychology; and systems theory interaction is the output of the system, or what was orig-
as described by von Bertalanffy (1968). The current inally described as occupational behavior. Feedback pro-
version of the MOHO is based on dynamical systems duces information to the person regarding current
theory and includes four principles upon which the rest behaviors and occupational performance, and the possi-
of the model is built (Kielhofner, 2002). These principles ble need for adaptation based on the feedback. Input
are displayed in Content Box 2-3. Key assumptions of refers to the information from the environment, which the
the MOHO that support these principles include the person processes via throughput.
following: Throughput is composed of the subsystems voli-
tion, habituation, and performance capacity. Volition
Humans have an innate need for occupation, and
refers to the process by which persons are motivated to
the ability to fulfill this need promotes health and
choose what they do. The volitional subsystem refers to
ones thoughts and feelings about the process of being
Health and wellbeing depend on a constant inter-
occupationally engaged. These thoughts and feelings
play between the person and the environment.
reflect a persons effectiveness to act in the world
These principles and assumptions are important (i.e., personal causation), what the person holds as
to consider when applying the MOHO to health- important (i.e., values), and what the person finds
promotion interventions. enjoyable and satisfying (i.e., interests).
According to Kielhofner (2004), the MOHO is a Habituation refers to a process whereby actions are
conceptual practice model. As such, it provides a frame- organized into routines and patterns. This area incorpo-
work for the therapist to investigate how people are mo- rates a persons habits of daily living (i.e., learned ways
tivated toward their occupations; how they perceive, of doing things that occur in an automatic way) and
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30 SECTION I Foundations and Key Concepts

roles (i.e., the development of an identity and the Environment

behaviors that engage the person in that role).
Performance capacity refers to and includes the
neurophysiological, cardiopulmonary, cognitive, and
mental capacities of individuals that help them carry Volition Participation
out and engage in occupations while interacting with
the environment; it refers both to the underlying Occupational
Habituation Performance
objective mental and physical abilities and to the lived Adaptation
experience that shapes performance (Kielhofner,
Performance Occupational
2004, p. 148). Over time, the construct of performance Skill
Capacity Competence
capacity has been increasingly viewed as blended
phenomena of objective and subjective components
(Kielhofner, Tham, Baz, & Hutson, 2008). The impor-
tance of mind-body unity on the lived body experience Figure 2-5 The Model of Human Occupation as a framework
is important to truly understand occupation at the per- for use in community-based practice.
formance level. For example, physical performance Adapted from A model of human occupation: Theory and application (3d ed.,
p. 121), by G. Kielhofner, 2002, Baltimore: Lippincott, Williams & Wilkins.
and the desire to engage in physical activity can be Copyright 2002 by Lippincott, Williams & Wilkins.
affected by mood. In addition, the quality of physical
performance can, in turn, impact mood.
The process of occupational adaptation has been ronment consists of groupings of humans and the
added to the MOHO. The three main constructs of expression of occupational forms those humans are
volition, habituation, and performance capacity are seen socialized into, based on group membership and set-
as continuously interacting with one another. Through ting (Kielhofner, 2004); it determines what behaviors
this interaction, a person, family, or community are appropriate in certain situations. For example, it
chooses to engage in meaningful habits and routines may be appropriate for occupational therapy students
that are supported by their abilities. In addition, they to be flirtatious at a wedding, but this same behavior
may choose to engage in occupations that stretch their could be considered sexual harassment within the
capabilities and through the process of occupational occupational form of the classroom or a fieldwork
adaptation refine their occupational identity and occu- site. The physical environment includes the space
pational competence: (e.g., reception hall, refugee camp, prison, or office
building) where occupational performance takes
Occupational adaptation is dynamic and context
place and the objects within that space (e.g., tables,
dependent; therefore what a person does in work, play,
tents, gravel, or security portals).
and self-care is a function of the interaction among
The model was originally developed as a hierarchi-
person, characteristics of motivation, life patterns, and
cal system (Kielhofner, 1985b). Current thinking is that
performance capacity with the environment. All clients
the process of occupational performance more closely
have the potential for change and to become more oc-
resembles a heterarchy versus a hierarchy and that a
cupationally adaptive through occupational therapy.
contextually based dynamic resonance exists among
(Kielhofner, Forsyth, & Barrett, 2003, p. 213)
phenomena. Heterarchy is manifest throughout
Figure 2-5 displays the process of occupational human occupation. When we consider any thought,
adaptation within the MOHO. In this process, occu- emotion, or action, the parts of the human being and
pational identity is the sense of self that humans or environment cooperate together according to local con-
communities develop over time through reflection ditions created by what each element brings to the total
upon the results of their active selection and engage- dynamic (Kielhofner, 2002, p. 35). Kielhofner and
ment in meaningful occupation. The additional con- colleagues continue to refine the model and be influ-
struct of occupational competence is viewed as the enced by changes in theory development in other disci-
sustainability of a pattern of occupation that is con- plines and the advent of new theories.
gruent with a persons or communitys occupational
identity (Kielhofner, 2002). Model of Human Occupation:
The environment, which includes both social Applicability in Health Promotion
and physical dimensions, is a key construct in the Two of the three originators of the MOHO (Kielhofner,
MOHO. Nelsons construct of occupational form 2002) were contacted to seek their thoughts about
(1988) has been incorporated into the language used its application to health promotion. Their responses
to describe the social environment. The social envi- are presented in Content Boxes 2-4 and 2-5. Research
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 31

supports the belief of these theorists. For example, a Content Box 2-5
health promotion study using the MOHO as the guid-
ing theory was conducted by Aubin, Hachey, and Dr. Gary Kielhofners Reflections
Mercier (1999). Their study examined the relationship on the MOHO
between subjective quality of life and meaningful daily
activity in a population of people with persistent and Question:
severe mental illness. Their findings suggested positive From your perspective, how do you see the MOHO
correlations between perceived competence in daily relating to the health and wellbeing of people?
tasks and rest, and pleasure in work and rest activities Response:
with subjective quality of life. Occupational interv In my view a fundamental aspect of health and well-
entions aimed at enhancing a sense of competence as being is how one participates in life occupations. This
defined by the MOHO were also supported. model is about the key factors that influence ones
choices about, pattern of, and ability for such partici-
The MOHO embraces the concept of ones partici- pation, along with the environmental support and
pation in society and involvement in a social role. barriers to such participation. . . . We decompose
Levy (1990) suggested that multiple occupational ther- occupational health and wellbeing (referred to as oc-
apy intervention principles can be used by therapists cupational adaptation) into the dual components of
and caregivers in the physical and cognitive rehabilita- developing an occupational identity and relying on
occupational competence.
tion of elders to facilitate participation in valued life
activities and social roles. Maintaining ones social
role enables continued competence and occupational The preceding examples support the use of the MOHO
adaptation in life, which, in turn, enables optimal par- in occupational therapy health promotion programming.
ticipation in daily living and enhances wellbeing and The interdisciplinary theoretical foundation of this model
quality of life. also makes it well suited for use in interdisciplinary
Dermody, Volkens, and Heater (1996) identified the health promotion programs with populations and com-
MOHO as being compatible with efforts to assist indi- munities. Those addressing the global health promotion
viduals in changing their health behaviors. Specifically, needs identified by the WHO (1986, 1997) have found
they stated that as humans make choices about engaging the MOHO to be a useful tool, whether those efforts are
in occupations within the environment, they can respond interdisciplinary or solely within occupational therapy.
in a healthy way and make healthy choices, which is This model has been introduced and adopted by occu-
consistent with being in a benign or adaptive cycle. pational therapists worldwide, as evidenced by MOHO
Humans also can make unhealthy choices and thus enter assessments being translated into 13 different languages
a vicious or maladaptive cycle. These and other research and by the scholarship cited at the MOHO Clearinghouse
studies support the constructs of the MOHO and its (UIC, 2005a, 2005b, 2005c). The MOHO has been
application to health promotion practice. identified as a model of choice to both understand and
assist in combating occupational apartheid (Abelenda,
Kielhofner, Suarez-Balcazar, & Kielhofner, 2005). Occup-
ational apartheid is defined as
Content Box 2-4
the segregation of groups of people through the restric-
Dr. Janice Burkes Reflections tion or denial of access to dignified and meaningful
on the MOHO participation in occupations of daily life on the basis of
race, color, disability, national origin, age, gender, sex-
Question: ual preference, religion, political beliefs, status in
From your perspective, how do you see the MOHO society, or other characteristics. Occasioned by politi-
relating to the health and wellbeing of people? cal forces, its systematic and pervasive social, cultural,
Response: and economic consequences jeopardize health and
Health and wellbeing is a fundamental core of the wellbeing as experienced by individuals, communities,
model. The foundation of the model is anchored in and societies. (Kronenberg & Pollard, 2005, p. 67)
recognition that all humans have a basic need to be
engaged in activities that are meaningful. Engage- The MOHO also has been used as a framework to
ment in meaningful activities serves as a catalyst to facilitate the return of displaced people to their home-
health and wellbeing in that a sense of competence, land (Algado & Cardona, 2005; see Content Box 2-6),
feelings of self efficacy, self-worth, and pleasure are to intervene with survivors of war (Algado &
evoked. Such feelings are hypothesized to evoke
health and wellbeing. Burgman, 2005), and to work with street children
in Mexico and Guatemala (Kronenberg, 2005). These
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32 SECTION I Foundations and Key Concepts

examples highlight the models potential cross-cultural wishes and concerns of its membersfor example,
use to promote occupational justice by addressing an occupational therapist organizing a stroke club
occupational apartheid through enhanced health and with monthly meetings at a local hospital per the
wellbeing. request of several families who met during the reha-
bilitation process.
Model of Human Occupation: Each month, the occupational therapist and a volun-
Health Promotion Example teer leader open a group discussion about health and
The MOHO can be used to support health promotion wellbeing issues affecting people coping with impair-
interventions at the community level. A community ments of daily living secondary to stroke. Volitional
can demonstrate volition through a shared history aspects of occupational performance are raised through
and vision expressed in a manner that supports the the identification of health and wellbeing issues critical
to the group. Continued member participation is fos-
tered through peer and professional support, as well as
Content Box 2-6 personal interest in discussing occupational perfor-
mance areas associated with living well with stroke.
MOHO Influenced Goals The group meets regularly, with a schedule design-
of a Community-Based Project ed to accommodate as many group members as possi-
The Volitional Subsystem
ble. In addition, the hospital arranged for transportation
in order to accommodate as many individuals
The objective was to prevent the loss of goals, as possible. With transportation provided and a sched-
interests, and values. We assisted community
members in analyzing their new life situation in ule that fits the groups needs, there is little room for
Guatemala, looking at their strengths and prob- developing a maladaptive habit of not attending the
lems, identifying new goals, and confronting their group. The group also discusses the development of
new reality. We encouraged the recovery of the val- habits and routines that support living longer and im-
ues inherent in Mayan culture, and in their cosmo- proving quality of life, such as smoking cessation,
vision. Finally, we attempted to promote an inner
locus of control through this empowerment, thus healthy eating, and regular participation in stress-
ensuring that the villagers saw themselves as the reducing occupations.
main characters in their life stories, and as sur- Performance capacity is addressed via the expres-
vivors. This is an especially important consideration sions of what people do in their daily lives to enact
in humanitarian interventions, since traditionally healthy habits. Barriers to health and wellbeing are
such work has adopted a paternalistic position.
discussed, and strategizing occurs through open
The Habituation Subsystem group discussion. Group members can then call upon
The goals were to encourage adolescents in the role individual (and group) volition in order to make
of community promoters and to return the role of new choices that support health and wellness or com-
guardians of ancient wisdom to the elders. Finally, mit further to these choices. There is constant multi-
we attempted to discourage damaging habits such as
alcoholism and its consequences (such as domestic directional interaction between the individual group
violence) by promoting healthier ways of life. members, the occupational therapist, the group as a
The Performance Subsystem
whole, and other entities, which promotes growth
and change. Over time, the group and its members
The goals were to develop new skills in emotional successfully employ strategies, and new occupa-
expression among the children, in community pro-
motion and carpentry among the adolescents, and tional identities evolve through heightened occupa-
the recovery of the traditional weaving skills among tional competence, demonstrating the benefits of
the adult women. a heterarchy.
The Environment
The goal was to develop income generating pro-
jects in order to address poverty. One of the most Occupational Adaptation (OA):
meaningful goals was the recovery of the cultural
cycle of the community.
Occupational adaptation was originally developed as a
Reprinted from Box 25-2 The return of the corn men: An interven-
tion project with a Mayan community of Guatemalan retornos, by frame of reference for linking the two primary con-
S. Sim-Algado and C. E. Cardona, 2005, in F. Kronenberg, S. S. structs of occupational therapy: occupation and adapta-
Algado, and N. Pollard (Eds.), Occupational therapy without borders: tion (Schkade & Schultz, 1992; Schultz, 2000; Schultz
Learning from the spirit of survivors (pp. 33650). New York:
Elsevier, Churchill Livingstone. Copyright 2005 by Elsevier, & Schkade, 1992). In later works, it was referred to as
Churchill Livingstone. With permission. a theory (Schultz & Schkade, 2003). The philosophical
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 33

assumptions that support this model resonate with represents the individuals desire for mastery, and the
health promotion and include the following: right side represents the environments demand for
mastery, while the middle represents the interplay
Competence in occupation is a lifelong process
between these forces. The desired outcome of this
of adaptation to internal and external demands
process is occupational adaptation:
to perform.
Demands to perform occur naturally as part of the Occupational adaptation is not about mastery per
persons occupational roles and the context se. Rather, it is the constant presence of the desire,
(person-occupational-environment interactions) demand, and press for mastery in occupational con-
in which they occur. texts that provide the impetus for adaptation. . . . The
Dysfunction occurs because the persons ability person seeking to respond masterfully in occupational
to adapt has been challenged to the point situations will engage in the adaptive processes.
that the demands for performance are not (Schultz & Schkade, 2003, p. 221)
satisfactorily met.
Mastery of ones health and wellbeing can often be
At any stage of life, the persons adaptive capac-
a difficult factor in a persons life but can be
ity can be overwhelmed by impairment, physical
secured through occupational adaptation. For example,
or emotional disability, and stressful life events.
a poor single mother of three who works as a cashier
The greater the level of dysfunction, the greater
is having a difficult time securing funds to feed her
the demand for changes in the persons adaptive
children. Based on a collaborative intervention pro-
cess with an occupational therapist, the mother is
Success in occupational performance is a direct
able to identify less expensive, healthier, quick meals
result of the persons ability to adapt with suffi-
compared to the fast food she had previously relied
cient mastery to satisfy the self and others
on to feed her children. The desire to master mother-
(Schultz & Schkade, 2003, p. 220).
hood, together with the press from the environment
The relationships between the constructs are detail- to feed her children, resulted in her attending, at
ed in a diagram that appears in Figure 2-6. Schultz and her place of employment, a free interdisciplinary
Schkade (2003) noted that the diagram represents the workshop on low-cost healthy food and play activi-
individual at a specific moment in time. The flow and ties for young families.
interactions between the constructs at this point in This client-centered, occupation-focused theory can
time are displayed. Specifically, the diagrams left side assist with organizing evaluation and intervention, where

Desire for Press for Demand for

Mastery Mastery Mastery

Person Occupational Occupational

Systems Challenge Environment

Occupational Role
Expectations Incorporate into
Adaptive Occupational
Response Response

Figure 2-6 Schematic of occupational adaptation process.

Reproduced from the presentation Theory of Occupational Adaptation: Overview (slide # 2), by S. Schultz, n.d. Retrieved December 11, 2006, from
http://www.twu.edu/ot/post_phd.htm. With permission.
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34 SECTION I Foundations and Key Concepts

the desired outcome is the ability to adapt to occupa- The development of an adaptive response is a positive
tional challenges and develop occupational competence. way for people to develop healthy habits and promote
wellbeing in their lives and in their communities. The
The theory of occupational adaptation is intended to
originators of OA see a clear link between the OA theory
be used as a guide for intervention that capitalizes
and health promotion, as detailed in Content Box 2-7.
on the power of occupation as the primary tool to
In this theory, the client is the agent of change
enhance the adaptive capacity of those we serve. We
(Schkade & McClung, 2001). The desired outcome as
view the enhancement of adaptive capacity as a
applied to health promotion is for the client to gain suf-
fundamental tool for engendering competence in oc-
ficient knowledge and skills to be able to engage in the
cupational functioning. (S. Schultz, personal commu-
occupational adaptation process without the presence
nication, February 2003)
of an occupational therapist or occupational therapy
In planning interventions, the OA model also presents assistant. According to AOTAs Framework (2008),
two alternatives: occupational readiness and occupa- the term client can represent an individual, a group
tional activity (Schultz & Schkade, 2003). Occupational (e.g., a family), or a population (e.g., an organization,
readiness works with facilitating client factors (e.g., a community).
movement functions, thought functions, mental func- Adaptive energy, which includes both primary and
tions of language) that are barriers to occupational secondary energy, is an important construct in this
performance. Working on increasing endurance through model when used for health promotion interventions
graded physical activity and instruction in energy con- and programming. It is particularly relevant for
servation are examples of occupational readiness. Occu- addressing health habits and routines. Primary energy
pational activity is the use of a client-selected occupation describes the process of engaged, intentional focus in
related to the individuals occupational roles. For exam- an occupation. The term secondary energy describes
ple, the client may choose to develop tolerance for walk- the phenomena of creative solutions appearing to a
ing in the community to complete instrumental activities problem while the individual is engaged in tasks unre-
of daily living (IADLs), such as home and health man- lated to the current occupational challenge. Schkade
agement and shopping. The client would then develop and McClung (2001) used a students writers block to
and execute a plan to achieve this goal (e.g., starting first describe the two types of adaptive energy. The student
with a walk to the mailbox located at the end of the dri- was spending a great deal of primary energy without
veway, increasing to a walk to the corner drugstore for a
prescription, and then a walk to a strip mall that is four
blocks away). In this example, the client uses the capac- Content Box 2-7
ity and knowledge gained through occupational readi- Dr. Sally Schultzs Reflections
ness to independently plan an approach that can lead to
ongoing occupational adaptation.
on OA Theory
From your perspective, how do you see OA theory
Occupational Adaptation: relating to the health and wellbeing of people?
Applicability in Health Promotion
There appears to be increasing acceptance of and
research utilizing OA (Honaker, 1999; Reitz & Scaffa, Health and wellbeing are relative. They are relative
2001; Schultz & Schkade, 2003) as an occupational to the ability to participate in life.
therapy theory. The principles of the theory are sound, Satisfying participation in life in the presence of
as they are built upon the constructs of occupation and both facilitators and inhibitors, constitutes relative
health and wellbeing.
adaptation, which have been utilized since the profes-
sions inception. While other models encourage the devel- Satisfying participation in life is a function of com-
opment of skills to promote adaptation, this approach petence in occupational functioning.
supports the development of clients adaptiveness so Competence in occupational functioning is a func-
they can determine which skills are needed and how to tion of adaptive capacity and resulting adaptiveness.
gain the needed skills (Schkade, Schultz, & McClung, Adaptiveness in occupational pursuits develops as
2000). This approach is consistent with the goal of sus- a function of the development and maintenance of
tainability, which is an essential component for the an innate occupational adaptation process.
long-term success of health promotion interventions. Therefore, adaptive function or adaptation is the
Using this theory, health promotion programming may intervening variable between occupation and
participation in life or health and wellbeing.
be developed and sustained in a variety of contexts.
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 35

success (i.e., trying to develop a topic and outline for a in learning new home-management techniques to accom-
term paper). She took a break to knit a blanket for her modate current and probable future visual impairments.
baby, and when she returned to her schoolwork, she Due to Marks new-onset diabetes, the occupational ther-
had both an idea and a plan for her paper. This OA apy assistant also helps him adapt both his eating and
strategy, labeled shunting, enabled her to use secondary cooking routines and habits in order to develop a
energy to consider the problem while using primary en- healthier lifestyle (e.g., decreasing fried foods, increas-
ergy to knit (Schkade & McClung, 2001). Additional ing vegetable intake), thus meeting the demand for
examples of therapists applying this model to practice mastery. The occupational therapy assistant recognizes
were collected and reported by Schkade and McClung. that cooking is a meaningful occupation for Mark and
Although the majority of the examples focus on the thus helps him find large-print healthful recipes online
rehabilitation process, the examples help illustrate the that are within his budget to prepare.
models principles and process. Mark begins to develop occupational competence by
Research on the OA process supports its use in meeting the occupational challenge for adaptation. The
occupational therapy and occupational therapy in press for mastery exists for Mark, and he meets the chal-
health promotion. Honaker (1999) studied patterns of lenge with enthusiasm. While Mark learns adaptive
adaptation in elders with rheumatoid arthritis (RA) rel- strategies for lifestyle enhancement in home manage-
ative to choices made when presented with occupa- ment, the occupational therapy assistant also addresses
tional challenges. The author explored how elders with his work situation. Together, they strategize to adapt both
RA adapted in order to pursue meaningful occupation, transportation and work areas in order for Mark to be
whether a sense of mastery was experienced, and safe with community mobility and explore areas of work
whether a perceived relationship existed between occu- in which he can still engage. Mark begins to recognize
pational participation and pain. Results of this study that the visual adaptive strategies learned at home can
showed that elders with RA continued to pursue mean- be used at work and begins to develop a level of mastery
ingful occupation despite pain but experienced a dimin- in occupational adaptation that supports a healthier life-
ished sense of efficiency and mastery. style on both a physical and psychosocial level.
Through ones desire for mastery, OA acknowledges
environmental influences on mastery and examines
demands for mastery. There is a consistency in philos- Person-Environment-Occupation
ophy between OA and the WHO definition of health
promotion, which is the process of enabling people to
(PEO): Overview
increase control over, and to improve, their health In the PEO model, individuals are viewed holistically
(WHO, 1997, p. 1). This process also can be viewed as with their unique combination of physical, cognitive,
developing mastery over ones health in order to opti- and affective characteristics and their life experiences.
mize wellbeing. This theory has excellent potential for The primary assumption of the model is that the person
use in the creation of holistic health promotion inter- is intrinsically motivated and continually developing.
ventions and programs, and it matches the philosophy The person in the model can refer to an individual, a
of the profession and the principles of high-level well- group, or an organization (Strong et al., 1999). The
ness initiated by Dunn (1954), a progressive physician. model has three main constructs: person, environment,
and occupation.
Occupational Adaptation: Environment in the model is defined as the physi-
Health Promotion Example cal, social, and cultural elements of the context in
Mark is a 45-year-old African American with new-onset which occupational performance takes place. The envi-
diabetes and beginning visual impairments who was ronment provides cues about appropriate and expected
recently released from the hospital. He is single and works behaviors. The environments characteristics can enable
in a rehabilitation facility for people with substance-abuse or constrain occupational performance. The environ-
issues. He is a former substance abuser. ment is conceptualized on both the micro and macro
The onset of visual impairments and the health levels. A micro level view of the environment focuses
issues related to diabetes have affected abilities and on the individuals context at home, work, school, and
roles important to him as he copes with his new life sit- so on, and how this environment affects the persons
uation. He wishes to return to work as soon as possible occupational performance. The macro level view of the
to avoid going on welfare. He receives occupational environment has a population-based perspective and
therapy at home, limited to a small number of visits. focuses on the environmental variables that affect
The occupational therapy assistant, under indirect the occupational performance of groups of people.
supervision of an occupational therapist, engages Mark Environmental fit refers to the degree of congruence
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36 SECTION I Foundations and Key Concepts

among the PEO components. A good fit results in performance. In the PEO model, occupational perfor-
optimal occupational performance for the individual mance is the outcome or product of the dynamic rela-
(Cooper, Letts, Rigby, Stewart, & Strong, 2001), fam- tionship between the person, the environment, and the
ily, or community. occupation (Law, Baum, & Dunn, 2001). This is rep-
Adaptation is a function of environmental fit. When resented in Figure 2-7 as the intersection of the three
a person is functioning well in a new context, they can spheres. A greater degree of overlap of the three
be said to have adapted well to that environment. This spheres indicates a better fit between the person,
implies a positive and supportive relationship between the environment, and the occupation. The focus of
the person and the environment. However, it is impor- intervention is on improving PEO congruence and
tant to note that the person and the environment are thereby enhancing occupational performance. As a
constantly changing, and therefore adaptation is a con- result, multiple options for change can be generated
tinual process (Letts et al., 1994). The model also rec- (Strong et al., 1999).
ognizes that problems associated with disability
may not be due to the disability itself but rather are the Person-Environment-Occupation:
result of a poor person-environment fit. In cases such Applicability to Health Promotion
as this, intervention may consist of changing the envi- Law, one of the originators of the PEO, described the
ronment to meet the individuals needs, rather than relationship between PEO and the facilitation of health
trying to change the person to fit the environment and wellbeing (Content Box 2-8). Occupational therapy
(Law et al., 1996). health promotion interventions can facilitate changes in
According to the PEO model, occupations are clus- the person, the environment, or the occupation in order
ters of tasks and include self-care, leisure, and pro- to enhance occupational performance, health, and well-
ductive pursuits. Occupations satisfy an individuals being. Interventions that address all three elements
needs for self-maintenance, self-expression, and life the person, the environment, and the occupationare
satisfaction. Meaningful engagement in occupations more likely to be effective (Stewart et al., 2003) and
is health promoting and enhances quality of life. The have greater sustainability. Increasing access to work,
model conceptualizes activities, tasks, and occupa- school, and recreational environments and modifying/
tions as nested concepts. Activities are the basic units adapting occupations can facilitate improved health
of tasks, and tasks are sets of purposeful activities that and occupational performance. Improving skills and
make up meaningful occupations. Occupations are
groups of self-directed, functional tasks and activities
in which a person engages over a life span (Stewart
et al., 2003, p. 229).
Occupational performance is the product of the
person-environment-occupation transaction. Occupa-
tional performance requires that persons mediate the A
Person Environment
sometimes conflicting demands of the environment
with their view of themselves and their ever changing D
needs and priorities. Some elements of occupational
performance can be measured objectively through
observation, while subjective experiences are best mea-
sured through self-report (Law et al., 1996).
The PEO model emphasizes the physical, social, Occupation
and cultural factors in the environment that hinder or
facilitate occupational performance. It recognizes
the developmental nature of the person-environment- Key:
occupation interaction and the individuals changing A = person-environment interaction
needs, roles, expectations, and goals across life stages B = person-occupation interaction
C = environment-occupation interaction
(Law & Baum, 2001).
D = person-environment-occupation interaction
Traditional occupational therapy evaluation mea- (occupational performance)
sured aspects of the person, environment, and occupa-
tion as discrete entities. The PEO model advocates Figure 2-7 The person-environment-occupation framework.
measurement of the various interfaces of the PEO Developed from Measuring occupational performance: Supporting best practice
in occupational therapy (p. 41), by M. Law, C. Baum, & W. Dunn, 2001, Thoro-
relationship in order to provide a more complete fare, NJ: SLACK. Courtesy of Jenny Wingrat. Copyright 2001 by SLACK.
understanding of the variables that affect occupational Reprinted with permission.
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 37

capabilities of individuals, families, and groups can Person-Environment-Occupation:

enhance occupational performance and the health of Health Promotion Example
communities and populations. An occupational therapist was contracted as a consul-
Applications of the PEO model have been investigated tant for an existing transitional living program for
through both quantitative and qualitative research. Several homeless women and children. The program was not
studies have tested the effectiveness of the PEO model meeting its objectives and was in need of expert advice.
with various populations, including older adults (Cooper The PEO model was used to evaluate the program and
& Stewart, 1997) and persons in recovery (Strong, 1998). make recommendations for improvement.
The model has been used in Canada, the United States, The evaluation and intervention took place in a
Russia, India, and Bosnia (Strong et al., 1999). It also was 15-apartment, transitional-living facility (microenvi-
used to help create a family-centered framework for ther- ronment) in the midtown region of a southern city with
apy with children who have cerebral palsy; although the a population of approximately 200,000 (macroenviron-
model was not identified by name, the influence and ment). The person in this example refers to a group
interplay of the child (i.e., person), tasks (i.e., occupa- of 15 homeless women and their children who are res-
tion), and environment were major components of the idents of the transitional living apartment complex. The
family-centered framework (Law et al., 1998). programs goal is to enable the 15 families to obtain
The PEO model is flexible, easily understood, and and maintain their own housing in the community. Par-
can be used with people of all ages in a variety of set- ticipants are allowed to remain in the transitional living
tings. This model has the potential to facilitate a shift in apartments for a maximum of 18 months. The average
practice from a narrow focus on performance compo- length of stay over the past 5 years has been 12 months.
nents to a broader emphasis on occupational perfor- The occupational therapist evaluated the characteris-
mance. The model provides occupational therapists with tics of the microenvironment and found that, in general,
a framework for analyzing occupational performance there was little social support evident among the fami-
problems, planning interventions, measuring outcomes, lies. They rarely interacted, except when engaged in
and articulating the uniqueness of occupational therapy structured program activities. All the women and chil-
practice (Strong et al., 1999). The models only limita- dren attended the same program activities. Program
tion is that it has not been extensively tested, as it is a staff made no attempt to customize the program to
relatively new practice model. individual participant needs or to change program ele-
ments over time. The families rarely participated in
community events, other than to attend program-
Content Box 2-8 required activities in community locations, such as
12-step meetings. However, the city (macroenviron-
Dr. Mary Laws Reflections ment) was abundant in resources. A community center
on PEO Theory providing after-school activities was within walking
distance of the apartments. The city provided numerous
Question: no-cost or low-cost leisure opportunities, a variety of
From your perspective, how do you see PEO relating levels of educational and vocational training programs,
to the health and wellbeing of people? and a diverse economic base with numerous job oppor-
Response: tunities. However, a major barrier was the limited
Notions included in health and wellness . . . can be transportation options to these community resources.
thought of in terms of person, environment and occu- A large percentage (70%) of the women and children
pation. For example, health and wellness can include
happiness, physical vigor, and personal safety, poten-
were victims of domestic violence, and 50% of the
tially all elements found within the person. Similarly, women had substance-abuse problems. A few were in
health and wellness can include access to meaningful legal trouble and were remanded to the program by
activities, work, leisure or school, elements of occu- the court. Many of the women had been previously
pation. Finally, health and wellness can include access employed but had minimal work skills. None of the
to social networks or financial stability, two of the
environments mentioned in the PEO.
women were currently employed. All the women indi-
The relationship between the PEO model and cated a desire to work, and some wanted to return to
health and wellness can be seen throughout daily liv- school to further their education. Many of the women
ing. For example, a person cannot achieve work satis- voiced a desire for parenting-skills training and nutrition
faction if they cannot physically enter the building, nor education. The children ranged in age from newborn to
can they experience happiness and personal safety if
their environment is full of hazardous elements.
adolescence, with most of the children of elementary
school age. All the children received developmental
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38 SECTION I Foundations and Key Concepts

screening, and one-third were found to be marginally owned cars. A local car dealership was contacted, and
delayed. The school system had identified several chil- a used car was donated for facility use. A local civic
dren as having learning disabilities, and some had obvi- organization provided the funds for insuring the
ous mental health needs. Few of the families had donated vehicle, and a sign-up system was initiated
received any health-care services in the past year. for the women to use the car. After a short time, the
The range of occupations available in the microenvi- women developed a system that met the needs of all
ronment was limited. Each family had its own apartment, the families. In addition, a local nonprofit transporta-
which facilitated participation in self-care occupations, tion agency offered 50% discounts on their services
both basic and instrumental. There was a coin-operated for the women to travel to work, school, or health-
laundry on-site, a group meeting room, and a small play- care appointments.
ground for the children. Facility policies prohibited fam- The PEO model continues to inform the evaluat-
ilies from inviting visitors to their apartments. Visitors ion and intervention process for these families, and
were allowed in the group meeting room, which was new program elements are being added on a regular
equipped with a kitchen, but the kitchen was off limits basis. The participants complex needs were readily
to residents. addressed by the transactional elements of the model.
A few of the problems identified by the occupational The COPM provided the women with a measure of
therapist included control and autonomy over the intervention goals and
activities, and it gave them a sense of ownership of the
limited social support in both the micro (facility)
results. This factor emerged as a particularly impor-
and macro (community) environments;
tant aspect of the intervention, as many of these
poor access to community resources (person-
women had lost motivation and exhibited low levels
environment transaction);
of self-efficacy.
minimal opportunities for participation in work
and play/leisure occupations (person-environment-
occupation transactions); Person-Environment-Occupation-
lack of customization of program activities to
family needs (person-occupation transactions). Performance Model (PEOP):
The occupational therapist recommended using the
Canadian Occupational Performance Measure (COPM) The PEOP model was initially referred to as the
to ascertain the families occupational needs and person-environment-performance framework. Originally,
priorities. The results would be used to customize the model was graphically designed as a set of three
program activities to meet the specific needs of nested boxes, with the person represented in the inner-
the women and their children. This necessitated most box embedded in the performance component
developing numerous program activities not currently in turn, embedded in the environment (Christiansen
provided, including parenting-skills training and & Baum, 1991). The subsequent version of the PEOP
nutrition education. Another recommendation was to used a triangle, with all subcomponents (i.e., self-
allow the women access to the kitchen in the group identity, roles, tasks, and actions) feeding into the
meeting room to prepare snacks for visitors and to development of occupational performance, which
prepare food for parties for the apartment complex res- then reflected a state of wellbeing (Christiansen &
idents. The families began celebrating birthdays and Baum, 1997). Occupational performance was seen to
holidays together, which facilitated the development be influenced by both intrinsic factors (e, g., psycho-
of social-support mechanisms within the microen- logical and biological) and extrinsic factors (e.g.,
vironment. In addition, computers, table games, and social and cultural).
other leisure resources were added to the group meet- In the latest iteration of the PEOP (Fig. 2-8), the
ing room, and the name of the space was changed to graphic representation more closely resembles the PEO
the community activities room. model, with the use of overlapping circles, which may
Addressing the problem of transportation and confuse students who are attempting to differentiate
access to community resources was a more challeng- between the models. However, the PEOP is differenti-
ing proposition. The bus system in this part of the ated from the PEO by the clear depiction of four con-
city was quite limited, with few routes and minimal structs (versus three) and by the projected outcomes. This
daytime service. The occupational therapist provided latest version more clearly illustrates the interrelationships
instruction on using the bus system, but this proved between the primary constructs (i.e., occupation, perfor-
inadequate for many of the families needs. Some of mance, person, and environment) and the desired out-
the women had drivers licenses, but none of them comes of occupational performance and participation,
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 39

wellbeing, and quality of life. Two basic assumptions Person-Environment-Occupational-

support the PEOP: Performance Model: Applicability
1. People are naturally motivated to explore their to Health Promotion
world and demonstrate mastery within it. The PEOP views health as an enabler and not as an out-
2. Situations in which people experience success come (C. Baum and C. Christiansen, personal commu-
help them feel good about themselves. This nication, February 2003). Health enables participation
motivates them to face new challenges with in everyday life. When people are healthy, they can opti-
greater confidence (Baum & Christiansen, mally participate in daily occupations that promote life
2005, p. 245). satisfaction and enhance quality of life. Participation
The PEOP is a client-centered, top-down approach may also be influenced by external factors, as noted in
that focuses on the interaction of environment, person, the model. These factors may be barriers to the promo-
and occupationincluding the actual performance of tion of health and wellbeing, thus occupational therapists
an occupation. can readily use the PEOP to begin identifying environ-
Occupation is described as part of a hierarchy of mental and personal barriers to health and explore, with
behaviors having differing levels of occupational the client, strategies to optimize participation.
complexity. Table 2-2 identifies these levels and pro- The PEOP can also be applied to community or
vides examples. The models intent is to guide inter- population-based health promotion initiatives. Alth-
vention using occupation and to enhance occupational ough the model contains four primary constructs,
performance for greater participation in the community many additional constructs are used to describe appli-
or world of meaning. It considers personal and environ- cations of this model in the literature. One of these
mental factors that enable or constrain societal partici- constructs, human agency, is of particular relevance in
pation. Baum and Law (1997) discussed the need for applying the model to health promotion. Human
interventions to be contextually based in order to agency has been described as the natural tendency of
achieve a state of occupational competence. When humans to be motivated to explore their worlds and
intervention is focused on context, as well as on activ- demonstrate mastery within it. To do this, the person
ities and occupations that have meaning and value must effectively use the resources (personal, social,
to the client, then health and wellbeing can be more and material) available in his or her environment
effectively improved. (Baum & Christiansen, 2005, p. 242). This important

Physiological Social Support


Cognitive Social and

Economic Systems

(Intrinsic Factors) AND (Extrinsic Factors)
Spiritual Culture and

Neurobehavioral Built Environment

and Technology
Psychological Natural

Wellbeing Quality of Life

Figure 2-8 The person-environment-occupation-performance framework.
Reproduced from Figure 11-1 in Person-environment-occupation-performance: An occupation-based framework (p. 246), by C. M. Baum & C. H. Christiansen, in Occupa-
tional therapy: Performance, participation, and well-being, C. H. Christiansen, C. M. Baum, & J. Bass-Haugen (Eds.), 2005, Thorofare, NJ: SLACK. Copyright 2005 by
SLACK. Reprinted with permission.
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40 SECTION I Foundations and Key Concepts

Table 22 A Hierarchy of Occupation-Related Terms and Behaviors

Term Example
Roles: Positions in society having expected responsibilities Adult child
Adult grandchild
Full-time employee
Occupations: Goal-directed pursuits that typically extend Shopping for self, parents, and grandparent
over time, have meaning to the performer, and involve
multiple tasks
Tasks: Combinations of actions sharing a common purpose Making a grocery list
recognized by the performer
Managing a grocery cart
Actions: Observable behaviors that are recognizable Lifting
Directing another to lift
Abilities: General traits or individual characteristics that support Attention, motor control, language
occupational performance

From Person-environment-occupation-performance: An occupation-based framework for practice (p. 252), by C. M. Baum & C. H. Christiansen
in C. H. Christiansen, C. M. Baum, and J. Bass-Haugen (Eds.), Occupational therapy: Performance, participation, and well-being, 2005, Thorofare,
NJ: SLACK. Copyright 2005 by SLACK. Reprinted with permission.

construct can be broadened by replacing the word per- correctly and comprehensively identifies the resources
son with community or population. and abilities available to overcome barriers to health
One of the strengths of this model that makes it ideal and participation.
for use in health promotion is that it provides a frame-
work, built upon the theory, to guide intervention. Person-Environment-Occupation-
Baum, Bass-Haugen, and Christiansen (2005) des- Performance Model:
cribed a situational analysis process based on the Health Promotion Example
model to assist occupational therapists in the develop- Billy is a 12-year-old with autism. He lives with both par-
ment of theory-driven health promotion programming. ents and a sister in a close-knit community in a small
This process appears to be a community version of the town on the East Coast. Billy has been in inclusive school
occupational profile described in the professions situations since he began school but has had much diffi-
Framework (AOTA, 2008). After gathering a commu- culty negotiating both the social and physical environ-
nitys occupational profile data and before initiating an ments (contexts) of his occupational role as student.
intervention, it must be determined whether the com- The occupational therapist works with Billy twice a
munity or populations needs can be best met through week. She focuses attention on engaging him in occu-
an occupational therapy approach. This is an important pational experiences that provide the just right chal-
feature and is consistent with the core values of the pro- lenge, which accounts for the intrinsic factors limiting
fession (AOTA, 1993). If the community could best be participation. Billys mother would like him to partici-
served by another discipline or by working colla- pate more actively in a sport to optimize his physical
boratively with another discipline, it is unethical to and mental health. Billy was given several choices and
proceed independently. chose basketball, one of his fathers favorite sports. The
Although there has been little research on the use of occupational therapist, in collaboration with Billy and
the PEOP, it appears to have relevance for occupational his mother, focus on his physical and cognitive
therapy health promotion interventions. These inter- strengths (intrinsic) in order to help him develop occu-
ventions can lead to positive health behavior changes pational competence. They also work with the school
when occupational therapists examine the interactive system (extrinsic) to enable Billy to participate actively
nature of persons, occupations, environments, and the in basketball. This is achieved by exploring the possi-
resultant occupational performance. Using the PEOPs bilities for his involvement as an active participant and
situation analysis process can ensure that the therapist, observer so that Billy maintains a sense of being able
in collaboration with the community or population, to participate on some level.
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 41

Billy has the support of his parents and sister at

home, each of whom plays basketball with Billy to fol-
low through with the intervention plan designed with
the occupational therapist. He also plays with team-
mates who, over time, have accommodated for Billys
needs to catch the ball and then process which direction
to run and throw the ball. The social support, directly
influenced by his occupational therapy plan, assists in
helping Billy attain a level of wellbeing and optimized
psychosocial and physical health that supports the
growth and development of any 12-year-old.

Recent Advancements
and Potentially New Models
The definition of occupation, the customary focus of its
use by individuals, and a growing realization that inter-
dependence may be the best outcome of its prescription
and use were discussed at the third annual conference
of the Society for the Study of Occupation: USA (SSO-
USA, 2004). Presentations related to interdependence,
transactional approaches, and complexity science prompt
the following questions: Is a broader definition of
occupation needed that emphasizes the interdepen-
dence of humans with the environment and each other
in the pursuit of occupation? Is this view of occupation Figure 2-9 Tai chi in Qingdao, China.
more compatible with health promotion interventions
and philosophy?
At first glance, the practice of tai chi displayed in occupational therapists quickly embraced one mem-
Figure 2-9 may appear to be individuals independently bers idea of using a river metaphor to better explain
engaging in the same occupation, but upon closer obser- the overall value of harmony, the goal of enhanced life
vation, the interdependent nature of the occupation flow, and the relationship between the models con-
becomes apparent. In time, will research find that inter- structs (Fig. 2-10). The constructs were reconceptual-
dependent occupations promote health and wellbeing ized to support the representation of a free-flowing
in more powerful ways than occupational engagement river as the ideal life (i.e., maximal life flow). While the
in isolation? A new theoretical model that expresses the final version included the original constructs, they were
interdependence of humans and nature is the Kawa renamed to better reflect an East Asian philosophical
(River) Model (Iwama, 2005a, 2005b, 2006a, 2006c; perspective, including beliefs from Buddhist, Confu-
Iwama et al, 2006; Lim & Iwama, 2006). cian, and Taoist philosophical orientations (Iwama,
2005a, 2006b, 2006c).
The Kawa (River) Model The Kawa Model was developed within a social
A Japanese Canadian occupational therapist worked structure that values interdependence and the collective
with a group of Japanese occupational therapists with more than independence and the self. Within this con-
the goal of designing an Eastern-influenced model text, the notion of self is embedded and interconnected
for occupational therapy practice (Iwama, 2005b). in a manner that precludes separation of the individual.
Through this process, the Kawa (River) Model was This model is best suited for clients, families, or com-
developed. The models first version appeared graphi- munities with comparable value systems. Since the
cally much like other Western models, with a series of models development, its application has been primar-
boxes imbedded in a circle, with arrows between the ily through case studies of individuals (Iwama, 2006a,
boxes to signify the relationships between constructs. 2006c). The three-dimensional aspects of the model
The constructs included environmental factors, life cir- can assist with visually identifying assets and liabilities
cumstances and problems, personal assets and liabili- through nontraditional techniques such as drawings
ties, and life flow and health. However, the Japanese and sculpture. Therefore, it may be particularly well
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42 SECTION I Foundations and Key Concepts

The end result of the above work will support the

professions continued movement toward providing
health promotion services to individuals, families, groups,
organizations, communities, and populations. To this
end, this chapter has provided a review of several occu-
pational therapy models and examples of their use in
health promotion. In addition to occupational therapy
theories and models, those from other disciplines also
can be useful tools in occupational therapy health pro-
motion. The next chapter will provide an overview of
several models from health psychology, health behavior,
and other areas that can further contribute to the work of
occupational therapy in promoting health and wellbeing
for people and their communities.
Figure 2-10 Major components of the Kawa (River) Model.
Water (mizu) represents the individuals, familys, or commu-
nitys life flow. Driftwood (ryuboku) represents assets and liabili- For Discussion and Review
ties. Rocks (iwa) represent life circumstances and problems.
Arrows represent pressures from the environment through the 1. What are the key similarities and differences
rivers side (kawa no soku-heki) and the river bottom (kawa no
zoko). Gaps represent spaces (sukima), which are potential
between the models described in this chapter?
areas to broaden through occupational therapy intervention and 2. Which model might provide guidance for developing
thus increase space to enhance life flow. a preventive, occupation-based intervention for mili-
From Kawa River Model website: Concepts and structures, by M. Iwama, 2006. tary families with loved ones deployed overseas?
Retrieved November 29, 2006, from http://www.kawamodel.com/.With permission. 3. Could the occupation-based intervention for these
military families be further strengthened by adding
constructs from another occupational therapy
suited as a potential tool for community-based health- model? Why or why not?
promotion programming through identification of assets 4. Which model would you select to guide an explo-
and liabilities, including environmental features and rative study of the occupational competency of new
problems, through the use of media or verbal tech- mothers? Why did you make this selection? Which
niques. Future developments of this model can be mon- other model may also be appropriate and why?
itored through the online Kawa Model Discussion 5. How would you determine which model has been
Forum: How Does Your River Flow? (Iwama, 2006b). most effective for studying health and social partic-
ipation of middle-aged adults in the United States?
Health promotion has historically been a practice area Research Questions
of occupational therapy (Reitz, 1992), and the authors 1. Which has more impact on the health of homeless
wish to facilitate its continued development. Contribu- women and children, a health promotion interven-
tions of occupational therapists and occupational ther- tion based on the MOHO or one based on the
apy assistants to health promotion interventions have PEO model?
not realized their full potential. In order to do so, it is 2. What is the relationship between resilience and
important for both occupational therapy theorists and adaptation? How do these constructs impact men-
therapists to tal health?
reflect on the relationship between health promo- 3. How does the environment impact a persons per-
tion, the Framework (AOTA, 2008), and the core ception of his or her health?
values and beliefs of the profession (AOTA, 1993), 4. Which occupational model(s) would support each
and on the beliefs of the professions founders and of the above potential research questions?
current leaders;
be knowledgeable of and able to apply theory
to evidence-based health promotion program
development; and The authors wish to express their appreciation to the fol-
be knowledgeable of and able to apply theory to lowing individuals who assisted with the preparation of
the evaluation of the outcomes of those programs. this chapter: Frederick D. Reitz and Grace E. Wenger.
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Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 43

References Brown, C., Cosgrove, N., & DeSelm, T. (1997). Barriers inter-
fering with life satisfaction for individuals with severe men-
tal illness. Psychiatric Rehabilitation Journal, 20(3), 6771.
Abelenda, J., Kielhofner, G., Suarez-Balcazar, Y., & Christiansen, C., & Baum, C. M. (Eds.). (1991). Occupational
Kielhofner, K. (2005). The model of human occupation as a therapy: Overcoming human performance and perfor-
conceptual tool for understanding and addressing occupa- mance deficits. Thorofare, NJ: SLACK.
tional apartheid. In F. Kronenberg, S. S. Algado, &
Christiansen, C., & Baum, C. M. (Eds.). (1997). Occupational
N. Pollard (Eds.), Occupational therapy without borders:
therapy: Enabling function and well-being (2d ed.). Thoro-
Learning from the spirit of survivors (pp. 18396).
fare, NJ: SLACK.
New York: Elsevier, Churchill Livingstone.
Cooper, B. A., Letts, L., Rigby, P. J., Stewart, D., & Strong, S.
Algado, S. S., & Burgman, I. (2005). Occupational therapy
(2001). Measuring environmental factors. In M. Law,
intervention with children survivors of war. In F. Kronenberg,
C. Baum, & W. Dunn (Eds.), Measuring occupational
S. S. Algado, & N. Pollard (Eds.), Occupational therapy
performance: Supporting best practice in occupational
without borders: Learning from the spirit of survivors
therapy (pp. 22956). Thorofare, NJ: SLACK.
(pp. 24560). New York: Elsevier, Churchill Livingstone.
Cooper, B., & Stewart, D. (1997). The effect of a transfer
Algado, S. S., & Cardona, C. E. (2005). The return of the corn
device in the homes of elderly people. Physical & Occupa-
men: An intervention project with a Mayan community of
tional Therapy in Geriatrics, 15, 6177.
Guatemalan retornos. In F. Kronenberg, S. S. Algado, &
N. Pollard (Eds.), Occupational therapy without borders: Crist, P. A., Royeen, C. B., & Schkade, J. K. (Eds.). (2000).
Learning from the spirit of survivors (pp. 33650). Infusing occupation into practice. Bethesda, MD: American
New York: Elsevier, Churchill Livingstone. Occupational Therapy Association.
American Occupational Therapy Association. (1993). Core val- Dailey, B., & Reitz, S. M. (2003, June). Occupational therapy
ues statement and attitudes of occupational therapy practice. services in the criminal justice system: Healthy life skills
American Journal of Occupational Therapy, 47, 108586. beyond the wall. Short course presented at the 83rd AOTA
Annual Conference & Exposition, Washington, DC.
American Occupational Therapy Association. (2005). Occupa-
tional therapy code of ethics (2005). Retrieved July 5, 2005, Dermody, J. L., Volkens, P. P., & Heater, S. L. (1996). Occupa-
from http://www.aota.org/general/about.asp#values. tional therapy students perspectives on occupations as an
agent that promotes healthful lifestyles. American Journal
American Occupational Therapy Association. (2008). Occupa-
of Occupational Therapy, 50(10), 83541.
tional therapy practice framework: Domain and process
(2nd ed.). American Journal of Occupational Therapy, Dunn, H. (1954). High-level wellness. Arlington, VA:
62, 62587. R.W. Beatty.
American Occupational Therapy Foundation. (2005). Collection Dunn, W., Brown, C., & McGuigan, A. (1994). The ecology of
of photographs from images of participation and health human performance: A framework for considering the effect
photo contest. Retrieved December 16, 2006, from of context. American Journal of Occupational Therapy,
http://www.aotf.org/html/photocontestlive.shtml. 48, 595607.
Aubin, G., Hachey, R., & Mercier, C. (1999). Meaning of daily Dunn, W., McClain, L. H., Brown, C., & Youngstrom, M. J.
activities and subjective quality of life in people with severe (2003). The ecology of human performance. In E. B.
mental illness. Scandinavian Journal of Occupational Crepeau, E. S. Cohn, & B. A. B. Schell (Eds.), Willard and
Therapy, 6, 5362. Spackmans occupational therapy (10th ed., pp. 22327).
Philadelphia: Lippincott, Williams & Wilkins.
Baum, C. M., Bass-Haugen, J., & Christiansen, C. H. (2005).
Person-environment-occupation-performance: A model for Honaker, D. K. (1999). The impact of occupational activities
planning interventions for individuals and organizations. In and wellness in elders. Masters thesis, Texas Womans
C. H. Christiansen, C. M. Baum, & J. Bass-Haugen (Eds.), University: Denton, TX.
Occupational therapy: Performance, participation and Iwama, M. K. (2005a). Situated meaning: An issue of culture,
well-being (3d ed., pp. 37292). Thorofare, NJ: SLACK. inclusion, and occupational therapy. In F. Kronenberg,
Baum, C. M., & Christiansen, C. H. (2005). Person-environment- S. S. Algado, & N. Pollard (Eds.), Occupational therapy
occupation-performance: An occupation-based framework without borders: Learning from the spirit of survivors
for practice. In C. H. Christiansen, C. M. Baum, & (pp. 12739). New York: Elsevier, Churchill Livingstone.
J. Bass-Haugen (Eds.), Occupational therapy: Performance, Iwama, M. K. (2005b). The Kawa (river) model: Nature, life
participation and well-being (3d ed., pp. 24266). Thoro- flow, and the power of culturally relevant occupational ther-
fare, NJ: SLACK. apy. In F. Kronenberg, S. S. Algado, & N. Pollard (Eds.),
Baum, C. M., & Law, M. (1997). Occupational therapy Occupational therapy without borders: Learning from the
practice: Focusing on occupational performance. American spirit of survivors (pp. 21327). New York:
Journal of Occupational Therapy, 51(4), 27788. Elsevier, Churchill Livingstone .
Bennett, S., Hoffman, T., McCluskey, A., McKenna, K., Iwama, M. K. (2006a). The Kawa model: Culturally relevant
Strong, J., & Tooth, L. (2003). Introducing OTseeker (occu- occupational therapy. New York: Elsevier, Churchill
pational therapy systematic evaluation of evidence): A new Livingstone.
evidence database for occupational therapists. [Evidence- Iwama, M. K. (2006b). The KAWA model discussion forum:
based practice forum]. American Journal of Occupational How does your river flow?: Index. Retrieved November 29,
Therapy, 57(3), 63538. 2006, from http://kawamodel.phpbbnow.com/.
1193_Ch02_022-045.qxd 6/8/09 5:38 PM Page 44

44 SECTION I Foundations and Key Concepts

Iwama, M. K. (2006c). The Kawa model website: Concepts Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., &
and structures. New York: Elsevier, Churchill Livingstone. Letts, L. (1996). The person-environment-occupation
Retrieved November 29, 2006, from http://www model: A transactive approach to occupational performance.
.kawamodel.com/. Canadian Journal of Occupational Therapy, 63(1), 923.
Iwama, M., Odawara, E., & Asaba, E. (2006, October). Cross Law, M., Darrah, J., Rosenbaum, P., Pollock, N., King,
cultural perspectives on occupation: What occupational G., Russell, D., Palisano, R., Harris, S., Walter, S., Armstrong,
science can gain from Japanese ways of knowing. Paper R., & Watts, J. (1998). Family-centered functional therapy
presented at the conference of the Society for the Study for children with cerebral palsy: An emerging practice
of Occupation, St. Louis, MO. model. Physical & Occupational Therapy in Pediatrics,
Kielhofner, G. (1980a). A model of human occupation, Part 2: 18(1), 83102.
Ontogenesis from the perspective of temporal adaptation. Letts, L., Law, M., Rigby, P., Cooper, B., Stewart, D., &
American Journal of Occupational Therapy, 34, 65763. Strong, S. (1994). Person-environment assessments in
Kielhofner, G. (1980b). A model of human occupation, Part 3: occupational therapy. American Journal of Occupational
Benign and vicious cycles. American Journal of Occupa- Therapy, 48(7), 60818.
tional Therapy, 34, 73137. Levy, L. L. (1990). Activity, social role retention, and the
Kielhofner, G. (1985a). Introduction. In G. Kielhofner (Ed.), multiple disabled aged: Strategies for intervention. Occupa-
A model of human occupation: Theory and application (pp. tional Therapy in Mental Health, 10(3), 130.
xviixx). Baltimore: Williams & Wilkins. Lim, K. H., & Iwama, M. K. (2006, July). The Kawa river
Kielhofner, G. (1985b). The open system dynamics of human model: Local to global utility. Paper presented at the confer-
occupation. In G. Kielhofner (Ed.), A model of human ence of the World Federation of Occupational Therapists,
occupation: Theory and application (pp. 3741). Baltimore: Sydney, Australia.
Williams & Wilkins. Lutz, C. S. (1998). Interdisciplinary prevention in rural com-
Kielhofner, G. (2002). A model of human occupation: Theory munities: Outcomes evaluation of the Strides for Life
and application (3d ed.). Baltimore: Lippincott, Williams & walking program for older adults. Unpublished graduate
Wilkins. project, Towson University, Towson, MD. (Supported
through USDHHS, Public Health Service, Bureau of Health
Kielhofner, G. (2004). Conceptual foundations of occupational Professions, Health Resources and Services Administration
therapy (4th ed.). Philadelphia: F. A. Davis. [Grant #36 AH 10043-4] administered by the Western
Kielhofner, G., & Burke, J. (1980). A model of human occupa- Maryland Area Health Education Center).
tion, Part 1. Conceptual framework and content. American Meyer, A. (1977). The philosophy of occupation therapy.
Journal of Occupational Therapy, 34(9), 57281. American Journal of Occupational Therapy, 31(10),
Kielhofner, G., Forsyth, K., & Barrett, L. (2003). Section II: 63942. (Original work published 1922.)
Model of human occupation. In E. B. Crepeau, E. S. Cohn, Miller, R. J., & Schwartz, K. (2004). What is theory, and why
& B. A. B. Schell (Eds.), Willard & Spackmans does it matter? In K. F. Walker & F. M. Ludwig (Eds.),
occupational therapy (10th ed., pp. 21219). Philadelphia: Perspectives on theory for the practice of occupational
Lippincott, Williams & Wilkins. therapy (3d ed., pp. 126). Austin, TX: Pro-Ed.
Kielhofner, G., & Igi, C. H. (1980). A model of human occupa- Mosey, A. C. (1981). Occupational therapy: Configuration of a
tion, Part 4: Assessment and intervention. American Journal profession. New York: Raven Press.
of Occupational Therapy, 34, 77788.
Nelson, D. (1988). Occupation: Form and performance. Ameri-
Kielhofner, G., Tham, K , Baz, T., & Hutson, H. (2008). can Journal of Occupational Therapy, 42(10), 63352.
Performance capacity and the live body. In G. Kielhofner
(Ed.), Model of human occupation: Theory and application Peloquin, S. M. (1989). Sustaining the art of practice. American
(4th ed., pp. 6848). Baltimore: Lippincott, Williams Journal of Occupational Therapy, 43(4), 21926.
& Wilkins. Peloquin, S. M. (2005). The 2005 Eleanor Clarke Slagle
Kronenberg, F. (2005). Occupational therapy with street chil- Lecture: Embracing our ethos, reclaiming our heart.
dren. In F. Kronenberg, S. S. Algado, & N. Pollard (Eds.), American Journal of Occupational Therapy, 59(6), 61125.
Occupational therapy without borders: Learning from the Ponicare, H. (n.d.). Science is facts, . . . . Retrieved October
spirit of survivors (pp. 26276). New York: Elsevier, 28, 2006, from http://www.quotationspage.com/subjects/
Churchill Livingstone. science/.
Kronenberg, F., & Pollard, N. (2005). Overcoming occupa- Reilly, M. (1962). Occupational therapy can be one of the great
tional apartheid: A preliminary exploration of the political ideas of the 20th century medicine. American Journal of
nature of occupational therapy. In F. Kronenberg, S. S. Occupational Therapy, 16(1), 19.
Algado, & N. Pollard (Eds.), Occupational therapy without Reilly, M. (1969). The educational process. American Journal
borders: Learning from the spirit of survivors (pp. 5886). of Occupational Therapy, 13(4), 299307.
New York: Elsevier, Churchill Livingstone.
Reilly, M. (1974). Play as exploratory learning. Beverly Hills,
Law, M., & Baum, C. (2001). Measurement in occupational CA: Sage.
therapy. In M. Law, C. Baum, & W. Dunn (Eds.), Measur-
ing occupational performance: Supporting best practice Reitz, S. M. (1992). A historical review of occupational
in occupational therapy. Thorofare, NJ: SLACK. therapys role in preventive health and wellness. American
Journal of Occupational Therapy, 46, 5055.
Law, M., Baum, C., & Dunn, W. (2001). Measuring occupa-
tional performance: Supporting best practice in occupa- Reitz, S. M. (1998a). Bridging the gulf between theory and
tional therapy. Thorofare, NJ: SLACK. practice. Poster session presented at the 12th International
1193_Ch02_022-045.qxd 6/8/09 5:38 PM Page 45

Chapter 2 Occupational Therapy Conceptual Models for Health Promotion Practice 45

Congress of the World Federation of Occupational Society for the Study of Occupation: USA. (2004). Conference
Therapists, Montral, Canada. abstracts: Third annual research conference. Retrieved
Reitz, S. M. (1998b). Ways to organize OT knowledge. Course December 26, 2006, from http://www.sso-usa.org/prior
packet, (OCTH 211). Towson, MD: Towson University. _conference.htm#ThirdAnnual.
Reitz, S. M. (2000). Ways to organize OT knowledge. Course Stevenson, S. (1998). Interdisciplinary prevention in rural com-
packet, (OCTH 11). Towson, MD: Towson University. munities: Outcome evaluation of the Strides for Life
walking program for older adults. Unpublished graduate
Reitz, S. M., & Scaffa, M. (2001). Theoretical frameworks for project, Towson University, Towson, MD. (Supported
community-based practice. In M. Scaffa (Ed.), Occupa- through USDHHS, Public Health Service, Bureau of Health
tional therapy in community-based practice settings Professions, Health Resources and Services Administration
(pp. 5184). Philadelphia: F. A. Davis. [Grant #36 AH 10043-4] administered by the Western
Royeen, C. B. (2000). Foreword: The scholarship of Maryland Area Health Education Center).
application. In P. A. Crist, C. B. Royeen, & J. K. Schkade Stewart, D., Letts, L., Law, M., Cooper, B. A., Strong, S., &
(Eds.), Infusing occupation into practice (pp. vvi). Rigby, P. J. (2003). Section V: The person-environment-
Bethesda, MD: American Occupational Therapy occupation model. In E. B. Crepeau, E. S. Cohn, & B. A.
Association. Schell (Eds.), Willard & Spackmans occupational therapy
Scaffa, M. (1992). The development of comprehensive theory in (10th ed., pp. 22731). Philadelphia: Lippincott, Williams
health education: A feasibility study. (Dissertation & Wilkins.
Abstracts International). Strong, S. (1998). Meaningful work in supportive environ-
Schkade, J. K., & McClung, M. (2001). Occupational adapta- ments: Experiences with the recovery process. American
tion in practice: Concepts in practice. Thorofare, NJ: Journal of Occupational Therapy, 52, 3138.
SLACK. Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., &
Schkade, J. K., & Schultz, S. (1992). Occupational adaptation: Cooper, B. (1999). Application of the person-environment-
Toward a holistic approach for contemporary practice, part 1. occupation model: A practical tool. Canadian Journal
American Journal of Occupational Therapy, 46, 82937. of Occupational Therapy, 66(3), 12233.
Schkade, J., Schultz, S., & McClung, M. (2000, March). University of Illinois at Chicago, MOHO Clearinghouse.
Occupational adaptation: Status 2000. Paper presented at (2005a). Introduction to MOHO. Retrieved July 23, 2005,
the meeting of the American Occupational Therapy Associ- from http://www.moho.uic.edu/intro.html.
ation, Seattle, WA. University of Illinois at Chicago, MOHO Clearinghouse.
Schultz, S. (2000). Overview of theoretical models: Occupa- (2005b). Frequently asked questions. Retrieved July 23,
tional adaptation. In P. A. Crist, C. B. Royeen, & J. K. 2005, from http://www.moho.uic.edu/faq.html.
Schkade (Eds.), Infusing occupation into practice (2d ed., University of Illinois at Chicago, MOHO Clearinghouse.
pp. 615). Bethesda, MD: American Occupational Therapy (2005c). References list. Retrieved July 23, 2005, from
Association. http://www.moho.uic.edu/referencelists.html.
Schultz, S. (n.d.). Theory of occupational adaptation: von Bertalanffy, L. (1968). General system theory: Founda-
Overview. Retrieved December 11, 2006, from http://www tions, development, applications. New York: George
.twu.edu/ot/post_phd.htm. Braziller.
Schultz, S., & Schkade, J. K. (1992). Occupational adaptation: World Health Organization. (1986). Ottawa charter for health
Toward a holistic approach for contemporary practice, part promotion. Retrieved December 4, 2004, from http://www
2. American Journal of Occupational Therapy, 46, 91725. .who.int/hpr/NPH/docs/ottawa_charter_hp.pdf.
Schultz, S., & Schkade, J. K. (2003). Section III: Occupational World Health Organization. (1997). Jakarta declaration on
adaptation. In E. B. Crepeau, E. S. Cohn, & B. A. Schell leading health promotion into the 21st century. Retrieved
(Eds.), Willard & Spackmans occupational therapy May 29, 2005, from http://www.who.int/hpr/NPH/docs/
(10th ed., pp. 22023). Philadelphia: Lippincott, Williams jakarta_declaration_en.pdf.
& Wilkins.
World Health Organization. (2001). International classification
Scott, P., Miller, R. J., & Walker, K. F. (2004). Gary Kielhofner. of functioning, disability and health. Geneva, Switzerland:
In K. F. Walker & F. M. Ludwig (Eds.), Perspectives on Author.
theory for the practice of occupational therapy (3d ed., pp.
267326). Austin, TX: Pro-Ed.
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Chapter 3

Health Behavior Frameworks

for Health Promotion Practice
S. Maggie Reitz, Marjorie E. Scaffa, Regina Michael Campbell,
and Patricia Atwell Rhynders

Theory gives planners tools for moving beyond intuition to design and evaluate health
behavior and health promotion interventions based on understanding of behavior. It helps
them to step back and consider the larger picture. Like an artist, a program planner who
grounds health interventions in theory creates innovative ways to address specific cir-
cumstances. He or she does not depend on a paint-by-numbers approach, re-hashing
stale ideas, but uses a palette of behavior theories, skillfully applying them to develop
unique, tailored solutions to problems.
National Cancer Institute [NCI], 2005, pp. 45

Learning Objectives
This chapter is designed to enable the reader to:
Identify theories from other disciplines for poten- Compare and contrast one occupational therapy
tial application to occupational therapy health model or theory with a model or theory from
promotion initiatives. another discipline and explain how these might
Evaluate the advantages and disadvantages of be combined to better address a health promo-
the various models for use in occupational ther- tion need and develop an effective health
apy health promotion interventions in a variety promotion program.
of contexts.
Describe the potential application of a variety of
models from other disciplines as theoretical support
for occupation-based health promotion programs.

K e y Te r m s
Action stage Innovation Perceived barriers Self-organization
Bifurcations Innovators Perceived benefits Self-similarity
Contemplation stage Laggards Perceived severity Sensitivity to initial
Cues to action Late majority Perceived susceptibility conditions
Early adopters Macrosystem Precontemplation stage Social climate
Early majority Maintenance stage Predisposing factors Social ecology
Enabling factors Mesosystem Preparation stage Termination stage
Health-promotive Microsystem Reinforcing factors
environments Ontosystem Self-efficacy

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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 47

Introduction and practitioners describe the relationships of health

promotion initiatives to both the pattern of daily life and
While occupational therapy theories frequently focus on the enhancement of health. The description of the con-
the adaptation and recovery of individuals, theories from sultation process, education process, and advocacy, as
other disciplines often focus on behavior change and well as the examples of intervention approaches are par-
prevention at the group, population, or societal levels. ticularly relevant. The Framework is an excellent starting
Knowledge of occupational therapy theories and those point but is not entirely sufficient to guide practice in this
from other disciplines significantly enhances the reper- area. In addition to the Frameworks language and occu-
toire of occupational therapists and occupational therapy pational therapy process description, a theory-based
assistants involved in health promotion intervention. foundation is also required to support development and
Health promotion is described in detail in the American implementation of evidence-based interventions.
Occupational Therapy Associations (AOTAs) official In addition to occupational therapy theories and
statement on health promotion, Occupational Therapy conceptual practice models, those from other disci-
Services in the Promotion of Health and the Prevention plines also can be useful tools in occupational therapy
of Disease and Disability (AOTA, 2008). In this docu- health promotion. Health behavior theories are particu-
ment and earlier versions of this document, health pro- larly relevant and can be divided into two major types:
motion is seen as a strategy to address health, wellbeing, explanatory and change (NCI, 2005). Figure 3-1 shows
and occupational justice with individuals and groups as the relationship between these types of health behavior
well as other levels of society including, organizations, theories. Explanatory theory, also referred to as theory
communities, and governmental agencies. of the problem, seeks to discover why a health condi-
Five theories and models from a variety of health tion exists and to identify modifiable factors (e.g.,
and social sciences are reviewed in this chapter as access to resources, attitudes, knowledge, self-efficacy).
possible frameworks to supplement the use of occu- The Health Belief Model, discussed later in this
pational therapy conceptual practice models in health chapter, is an example of explanatory theory. Change
promotion practice: theory, also known as theory of action, is useful to
Diffusion of Innovations Theory direct decision-making around program interventions.
Health Belief Model (HBM) Diffusion of Innovation, which is also described in this
PRECEDE-PROCEED Model chapter, is an example of this type of theory.
Social Ecological Model Health behavior theories can also be classified
Transtheoretical Model of Change (TTM) according to their potential target: individuals, groups,
or communities. Table 3-1 identifies and classifies the
These theories are either from or were influenced by most prominent health behavior models currently
communication studies, health education, health pro- applied in the United States (NCI, 2005). They are cat-
motion, public health, psychology, or social psychol- egorized as addressing health issues at the individual
ogy. Schematics and health promotion examples are level, the interpersonal level, or the community level.
included for each of these theories. A selection of these models will be described in the
Discussion length for each theory and example
varies based on the theorys maturity and complexity.
In addition, the chapter also briefly introduces chaos
theory, which can contribute to the manner in which
occupational therapists and occupational therapy assis-
tants view balance and change in the development of Evaluation
health promotion initiatives. The chapter ends with a
Explanatory Change Theory
table that provides guidance in selecting theories Theory
appropriate for supporting health promotion initiatives. Behavior
Which strategies?
Why? Which messages?
What can Assumptions about
be changed? how a program
Health Behavior Theories: should work

An Overview Planning

The Occupational Therapy Practice Framework (AOTA,

Figure 3-1 Using explanatory theory and change theory to plan
2008) supports engagement in health promotion activi- and evaluate programs.
ties by occupational therapists and occupational therapy From Figure 1 in Theory at a glance (2d ed., p. 6), by National Cancer Institute,
assistants. Its language and philosophy help students 2005, Bethesda, MD: U.S. National Institutes of Health.
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48 SECTION I Foundations and Key Concepts

Table 31 Summary of Theories

Theory Focus Key Concepts

Individual Level Health Belief Model Individuals perceptions of Perceived susceptibility
the threat posed by a Perceived severity
health problem, the bene-
fits of avoiding the threat, Perceived benefits
and factors influencing the Perceived barriers
decision to act Cues to action
Stages of Change Model Individuals motivation and Precontemplation
readiness to change a Contemplation
problem behavior
Interpersonal Level Social Cognitive Theory Personal factors, environ- Reciprocal determinism
mental factors, and human Behavioral capability
behavior exert influence on
each other Expectations
Observational learning
Community Level Community Community-driven Empowerment
Organization approaches to assessing Community capacity
and solving health and
social problems Participation
Issue selection
Critical consciousness
Diffusion of Innovations How new ideas, products, Relative advantage
and practices spread within Compatibility
a society or from one soci-
ety to another
Communication Theory How different types of Media agenda setting
communication affect Public agenda setting
health behavior
Policy agenda setting
Problem identification, definition

From Table 11 in Theory at a glance (2d ed., p. 45), by National Cancer Institute, 2005, Bethesda, MD: U.S. National Institutes of Health.
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 49

following section, which includes those addressing Diffusion of Innovations:

individual health behavior as well as group and com-
munity models of health behavior change (Glanz, An Overview
Rimer, & Lewis, 2005; NCI, 2005). Those not selected The Diffusion of Innovations Theory was originally
are also potentially useful theories for occupational developed to describe the manner in which individuals
therapists. A good initial resource for the reader to adopt new products or behaviors. The theory has been
acquaint themselves with these other models is the NCI applied extensively to marketing and communications
publication Theory at a Glance (2005), available at research, to public health, and to education research.
http://www.cancer.gov/theory.pdf. Diffusion research has been supported by an invisible
Two of the five models to be described in detail college, an informal network of researchers who
are the Health Belief Model (Rosenstock, 1974; Rosen- form around an intellectual paradigm to study a com-
stock, Strecher, & Becker, 1994) and Prochaska and mon topic (Rogers, 1995, p. 44).
DiClementes Transtheoretical Model (1982, 1983, 1992). Rogers, a communications scholar who has written
Both are examples of widely researched individual or a series of books on the subject, defined diffusion as
intrapersonal health behavior models. The Health Belief the process by which an innovation is communicated
Model (HBM) examines the precursors of health behav- through certain channels over time among members of
ior. The Transtheoretical Model (TTM), also identified a social system (1995, p. 5). Although some researchers
as the Stages of Change Model by the NCI, explains the consider diffusion only as the spontaneous spread of an
various stages people experience as they seek to change idea or product, Rogers used the term to describe both
and maintain behaviors to maximize health and wellbe- the planned and unplanned spread of innovations. His
ing (DiClemente et al., 1991; McKenzie, Neiger, & use of the term innovation applies to an idea, practice,
Smeltzer, 2005). Diffusion of Innovations, identified in or object that is perceived as new by an individual or
Table 3-1, is a community-level theory. other unit of adoption (Rogers, 2003, p. 12). The
The remaining theoretical frameworks of health actual age of the innovation is irrelevant; it is the per-
behavior change to be described include the PRECEDE- ception of newness that characterizes an innovation.
PROCEED Model (designed for program planning For example, health promotion has been linked with
and evaluation) and the Social Ecology Model. These occupation and occupational therapy from the incep-
models and theories are most applicable to multilevel tion of the profession (Reitz, 1992) but as of yet has not
health promotion interventions that address the health been fully diffused into the profession.
needs of communities rather than individuals. In addi- Simply introducing a new construct, idea, or prac-
tion to these theories from the health and social science tice does not guarantee change. If that were the case,
literature, a theory from the physical sciences that will clients would make appropriate changes in their lives
be described, chaos theory, may prove beneficial in by merely being told of the value of healthy behav-
supporting health promotion practice. To date, this iors. There are characteristics of the innovation,
theory has not been extensively discussed in the health the adopter, and the organization that combine to
promotion literature; however, the authors believe affect the likelihood and rate of adoption (Rogers,
it has significant potential for application in health 1995). The four elements of the theory are detailed in
promotion. Table 3-2.

Table 32 Concepts in Diffusion of Innovations

Concept Definition
Innovation An idea, object, or practice that is thought to be new by an individual, organization,
or community
Communication channels The means of transmitting the new idea from one person to another
Social system A group of individuals who together adopt the innovation
Time How long it takes to adopt the innovation

From Theory at a glance (2d ed., p. 27), by National Cancer Institute, 2005, Bethesda, MD: National Institutes of Health.
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50 SECTION I Foundations and Key Concepts

Text/Image rights not available.

Individuals, organizations, and social systems can on the original idea of Tarde, a French social psychol-
be categorized according to their openness to adopt ogist in the early 1900s (Rogers, 2003).
innovations and the communication channels they use The curve starts slowly as innovative members of
to learn of new ideas. Innovators, the most daring of the social system adopt the innovation, then rises
all adopters, usually get ideas from sources outside steeply as the early adopters spread news of the inno-
their communities and put those ideas into use on a vations acceptance through the early majoritys inter-
local level. Because they are ahead of their time, personal networks. After the innovation has become the
they are not considered to be leaders among the major- standard practice, the curve tapers off, as there are few
ity. The early adopters are more widely known and individuals remaining who have not incorporated the
respected as opinion leaders. They serve as role mod- innovation within their practice.
els to those within the community and can influence Figure 3-3 displays the standard S-curve of adoption
adoption by raising awareness and persuading others for a new technology (Paulk, 1999). As mentioned ear-
to try the innovation. The early majority adopters lier, while health promotion has been associated with
value the opinions of the early adopters. They are the occupational therapy profession since its inception,
likely to have a wide circle of local peers but are not it has only recently approached the level of confirma-
seen as leaders. Because the early majority adopt just tion. Figure 3-4 depicts the S-curve of adoption for
before the skeptical late majority, they provide an
important connection in the diffusion process. The late Internalization
majority are persuaded by system norms and moti-
vated by peer pressure. Laggards are the last members Institutionalization
of the social system to adopt. They are the most tradi-
tional of the adopters and can least afford the risk Adoption
of trying something new (Rogers, 1995). Figure 3-2

displays the typical dispersion of a social systems Trial Use

members to these five categories; this dispersion
resembles the normal frequency distribution.
Phases of Diffusion
The action of diffusion is phased over time, first raising Awareness
awareness in the knowledge stage, then forming an Contact
opinion in the persuasion stage, moving to the decision
to adopt or reject implementation of the innovation,
and finally confirmation, when reinforcement for the Time
adoption decision is needed. When enough individuals Figure 3-3 The standard technology adoption S-curve.
have adopted an innovation, its diffusion becomes self-
From Structured approaches to managing change, by M. C. Paulk, 1999,
sustaining (Rogers, 1995). Rogers illustrated this as the Pittsburgh, PA: Carnegie Mellon University. Copyright 1999 by Carnegie
typical S-shaped curve of adoption, which was based Mellon University. Reprinted with permission.
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 51

1990s 2000s

AOTA Clark, et al. Fazio

Gilfoyle Moyer Scaffa

Barton Reilly Jaffe Nelson Townsend

Dunton West Finn White Pizzi Wilcock

Slagle Wiemer Johnson 1980s Reitz

1917 1960s 1970s

Figure 3-4 Adoption of health promotion in occupational therapy S-curve.

health promotion practice within the occupational Incentives and rewards for those who adopt an
therapy profession. Innovators and early adoptors of innovation facilitate successful implementation.
health promotion within the profession are identified. Change is often an uncomfortable prospect, so suffi-
Ely (1990, p. 298) described eight conditions that cient cause for change must exist, as well as an
facilitate the adoption, implementation, and institution- expectation that participation in the implementation
alization of educational innovations: will result in positive outcomes for those involved.
Individuals deem different incentives and rewards
Dissatisfaction with the status quo
desirable, so it is important to ascertain which incen-
Knowledge and skills
tives/rewards will be most effective. Involving imple-
menters in planning and decision-making facilitates
implementation. Communication is vital to theef-
forts success. It is imperative that each person feels
that he or she has had an opportunity to comment on
innovations that will directly affect his or her work
(Ely, 1990, p. 300).
One of the first prompts to change comes from dis- Stakeholder endorsement of the innovation enhances
satisfaction with the current situation or the way in the likelihood of implementation. Opinion leaders can
which things are done. It may result from a problem that have a profound effect on outcomes. Commitment from
cannot be solved with currently available methods. The superiors indicates support, which promotes confidence
greater the dissatisfaction, the more likely a person or in those who are empowered to incorporate the innova-
organization is to implement an innovation or change. tion into practice. Easily identifiable leadership is another
In order for an innovation to be implemented effectively, important element. Leaders encourage, inspire, and sup-
the persons involved must possess adequate knowledge port others in their implementation attempts. They must
and skills. If there is desire but knowledge and skills are ensure that the necessary materials and training are pro-
lacking, then successful implementation is unlikely. vided and are available for consultation should a problem
In-services, tutorials, and formal education are all occur (Ely, 1990).
strategies that can facilitate proper implementation. Ely (1990) suggested that these conditions be
Resources, including time, are essential elements for assessed before implementation is attempted. However,
implementation. Needed tools and materials should be he cautioned that although most of the conditions will
readily available, and personnel resources must be ade- apply most of the time (p. 303), cross-cultural com-
quate. Those responsible for implementing innovations parisons indicate some variations; therefore, adaptation
must have sufficient time to learn, adapt, integrate, and to specific situations may be necessary. Maximizing as
reflect on what they are doing (Ely, 1990, p. 299). many conditions as possible before and during the
Blocks of time should be set aside and designated adoption process will increase implementation effec-
specifically for tasks associated with implementation. tiveness: The conditions can be used as a screening
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52 SECTION I Foundations and Key Concepts

tool to identify potential problems, but they cannot be 2002). Another concern is that the theory provides
specific in determining the exact causes of the prob- minimal guidance on how to accomplish dissemina-
lems (Ely, 1990, p. 303). tion of innovative health promotion actions through
such strategies as interpersonal influence at the com-
Diffusion of Innovations: Applicability to munity level (Kennedy & Crosby, 2002). The impact
Health Promotion in Occupational Therapy of context on the dissemination process is an addi-
Although a limited amount of literature exists dis- tional challenge and is an area for needed research
cussing the use of Rogerss work in health promotion, (Oldenburg & Parcel, 2002). Occupational therapists
examples are available. Buller and colleagues (2005) and occupational therapy assistants, with their exper-
used the Diffusion of Innovations Theory to develop tise and knowledge of context and human perfor-
and disseminate a sun-protection program for outdoor mance, are in a position to enhance research efforts in
employees in ski areas. Other researchers compared this area.
tuberculosis (TB) therapy completion rates among jail Despite its limitations, the Diffusion of Innovation
inmates after their release (White et al., 2005). Compli- Theory has the potential to maximize success in the dis-
ance rates obtained through a clinical trial were com- semination of broad, multilevel health promotion com-
pared to those achieved from repeating the innovation munitywide programming (Oldenburg & Parcel, 2002).
in the real day-to-day world of a county jail. In the clin- The ultimate success of these efforts will be demon-
ical trial, the individuals providing the training did not strated in health outcomes that are linked to the
have additional duties beyond providing the TB educa- achievement of national health objectives, such as
tion and research. However, in the comparison group, Healthy People 2010: Understanding and Improving
the TB education protocol was added to the routine job Health (U.S. Department of Health and Human Ser-
duties performed by jail discharge planners. This vices [USDHHS], 2000). The Diffusion of Innovation
resulted in the training being provided in a shorter Theory exhibits potential for use in implementing or
timeframe and in a different setting (i.e., a private quiet replicating health promotion programs, including those
room for the clinical trial versus talking through the that are occupation-based, such as that described in the
bars in the real-world implementation). following example.
Although this study highlights the difficulties in trans-
lating evidence-based practice from the clinical trial Diffusion of Innovations:
environment to the realities of real-time service delivery, Health Promotion Example
it demonstrated that the Diffusion of Innovations Theory An occupational therapist wanted to implement a pro-
may be a helpful tool for researching the impact of dis- gram modeled after the Well Elderly Study, developed
semination approaches on health promotion programs. by University of Southern California (USC) faculty
The literature supports the use of the Diffusion of (Mandel, Jackson, Zemke, Nelson, & Clark, 1999), in
Innovation Theory, which has been identified as one of the assisted-living facility in which she works. She rec-
the few frequently used theories to support theory- ognized that the residents participation in occupations
driven health promotion program initiatives (Kegler, was limited. As a result, their occupational perfor-
Crosby, & DiClemente, 2002). By using the character- mance was deteriorating (dissatisfaction with the status
istics of innovation, the success of programs aimed at quo). This deterioration has impacted the residents and
encouraging the adoption of a new health behavior can the other facility staff, since they are being required to
be increased (NCI, 2005). In addition, the Diffusion of provide more and more care for the residents as their
Innovations Theory has been identified as promising for abilities decline. The occupational therapist had heard
use in disseminating new health promotion strategies or of the USC program but did not know how to imple-
programs (NCI, 2005; Oldenburg & Parcel, 2002). ment it, so she began by immersing herself in the pro-
As with any theory discussed in this chapter, oppor- fessional literature and contacting therapists who have
tunities exist for further development and research to implemented the program (knowledge and skills).
enhance strength and applicability. While descriptions When the occupational therapist felt comfortable
of program development based on this theory are with her knowledge level, she met with the facility
available, research comparing the efficacy and expense director to present a program proposal. The director
of various dissemination strategies remains underrep- was excited about the idea and gave the occupational
resented in the health promotion literature. This situa- therapist permission to proceed. In addition, the direc-
tion may be due to the need for different research tor agreed to provide the resources needed to imple-
strategies and measurement tools when studying the ment the program (commitment). The occupational
dissemination process than those traditionally used in therapist organized an in-service for the staff, provided
program effectiveness studies (Oldenburg & Parcel, information about the program (knowledge and skills),
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 53

and requested input from the staff regarding implemen- nosis accuracy, and acceptance of the diagnosis
tation. Staff members asked numerous questions and (Becker, 1974; Rosenstock et al., 1994). Perceived
provided strategies to overcome barriers to implemen- severity refers to a persons convictions regarding the
tation (participation). degree of seriousness of a given health problem. Per-
It became obvious to the occupational therapist that ceived benefits are a persons beliefs regarding the
the staffs complete cooperation and assistance would be availability and effectiveness of a variety of possible
required. It was decided that the staff needed more train- actions in reducing the threat of illness. Perceived
ing to increase the likelihood of successful implementa- barriers are the costs or negative aspects associated
tion. The facility director agreed to pay the employees with engaging in a specific health behavior. These bar-
for participating in the additional training (incentives riers can include fear of pain, inconvenience of seeking
and time). The occupational therapist identified team care, and expense (Rosenstock, 1966). Content Box 3-1
leaders to participate in the training and then train the identifies a variety of barriers to health promotion,
staff on their respective teams (leadership). Equipment, including perceived barriers and systems-level barriers
materials, and supplies were acquired, and the environ- to care. Cues to action are defined as instigating events
ment was modified to support the program (resources). that stimulatethe initiation of behavior. These cues may
Now the conditions are optimized to begin implementing be internal, such as perceptions of pain, or external,
a program tailored to maximize the wellbeing of the such as a famous person beginning an exercise plan or
facilitys residents. being diagnosed with breast cancer.
According to the model, in order for a person
to take action to avoid illness, the positive forces
Health Belief Model: must outweigh the negative forces. If an individual
believes that
An Overview
1. he or she is personally susceptible to the disease
The Health Belief Model (HBM) was originally devel-
or illness;
oped by social psychologists Hochbaum, Kegeles,
2. the occurrence of the health problem is severe
Leventhal, and Rosenstock to explain preventive
enough to negatively impact his or her life;
health behaviors (Rosenstock, 1974). Within a short
3. taking specific actions would have beneficial
time, it was adapted to study sick role (Becker, 1974)
and illness behavior (Kirscht, 1974). According to
4. the barriers to such action do not overwhelm
Rosenstock, the model is based on Lewins aspiration
the benefits; and
model, which is a special case of Lewins well-known
5. the individual is exposed to cues for action,
field theory (Maiman & Becker, 1974). Lewins work
then it is likely that the health behavior will
provided two underlying perspectives of the model:
occur (Rosenstock, 1974).
the phenomenological orientation and the ahistorical
perspective. According to Rosenstock, the founders Rosenstock (1966, 1974) hypothesized that the
of the HBM all agreed upon a phenomenological orien- required intensity of the cue to action could vary
tation where the individuals perceptions of self and depending upon the strength of the perceived threat.
the environment determine health behavior, not the Thus, if someone already felt a high level of perceived
actual environment. Their ahistorical perspective threat when riding a bicycle without a helmet, a bike
focuses attention on the current dynamics affecting an safety poster on a passing bus may be a sufficient cue
individuals behavior, not on past history or prior to purchase and wear a bike helmet. However, for
experiences, except if it directly relates to the current someone else with a lower degree of perceived threat,
issue (Rosenstock, 1974). the cue to action may need to be stronger, such as
The HBM describes the relationships between a their biking buddy taking a spill and receiving a mild
persons beliefs about health and his or her health- concussion.
specific behaviors. The beliefs that mediate health Perceived threat, which encompasses perceived
behavior, according to the original model, include susceptibility, has been suggested as an important first
perceived susceptibility, perceived severity, per- cognitive step in the health-action link described by
ceived benefits, and perceived barriers (Rosenstock, this model (Rosenstock et al., 1994). However, in
1966, 1974). Perceived susceptibility is the individ- addition to perceived threat, a person needs to believe
uals impression of their risk of contracting a disease that they have the resources to address that threat
or illness. Once a health condition exists, perceived before they take action. In order to maximize the like-
susceptibility expands to include perceived resus- lihood of ones engagement in a health behavior, the
ceptibility, perceptions regarding the belief in diag- individual must simultaneously
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54 SECTION I Foundations and Key Concepts

Content Box 3-1 which can include self-efficacy (McKenzie

et al., 2005).
Examples of Possible Barriers to Figure 3-5 presents a schematic representation
Health Promotion Services or Actions of the HBM with a new placement of the perceived
System Barriers susceptibility construct and the addition of self-
Fragmentation of services efficacy. Self-efficacy refers to a persons beliefs
Complex systems about their ability to coordinate skills and abilities to
Travel time attain desired goals in particular domains and circum-
Waiting time at appointment stances (Maddux, 2005, p. 278). These beliefs develop
Waiting interval for appointment through interaction with the environment during
Distance ones lifetime and are specific to particular skill sets
Transportation and goals.
Cost of services
Inadequate insurance coverage Health Belief Model: Applicability to Health
Transportation/parking Promotion in Occupational Therapy
Availability of Services
Limited office hours The HBM is one of the most widely studied and used
Health-care provider shortages frameworks for health behavior change (McKenzie
Organization of Services et al., 2005). It has been used to study and address
Lack of primary providers a wide array of health topics within varied popula-
Lack of case managers
Lack of continuum of care tions, including alcoholism (Bardsley & Beckman,
Discrimination 1988), compliance with a diabetes regimen (Becker
Race & Janz, 1985), exercise participation following
Sex myocardial infarction (Al-Ali & Haddad, 2004),
Geography (i.e., rural populations) medication compliance among psychiatric outpa-
Social status
Age tients (Kelly, Mamon, & Scott, 1987), and compli-
Stigma ance with home exercise programs (Chen, Neufeld,
Provider-Consumer Relationships Feely, & Skinner, 1999). As the aforementioned
Lack of expertise examples indicate, the HBM often focuses on health
Short encounters behaviors following the onset of a health condition. It
Demographic Factors
Education also can be used as a tool for prevention. Examples of
Low income such use include breast self-examination (Champion,
Age 1985), testicular self-examination (Reno, 1988),
Attitudes contraceptive behavior (Herold, 1983; Hester &
Lack of interest in health promotion Macrina, 1985), and, more recently, the health promo-
Fear or anxiety
Skepticism tion needs of young families (Roden, 2004a, 2004b),
Knowledge prostate cancer detection (Kleier, 2004), osteoporosis
Effort prevention (Cline & Worley, 2006; Turner, Hunt,
Cultural Factors DiBrezzo, & Jones, 2004), and physical activity
Preference for folk medicine participation (Centers for Disease Control and Pre-
Language vention [CDC], 1999; Juniper, Oman, Hamm, &
Family Characteristics Kerby, 2004).
Complexity of family Research on the model as a whole has been lim-
Family size ited; more attention has been given to examining its
Prior negative experience various constructs in isolation. In addition, the models
Adapted from Barriers: A critical review of recent literature, by K. A. predictive value is in question (Kegeles & Lund,
Melnyk, 2005, Nursing Research, 37(4), 196201. 1982). Although the constructs are fairly well
defined, the causal associations among the variables
and the reasons why particular factors are more
achieve a sufficient level of motivation to examine important in one population than another require fur-
the health issue; ther study. Also of concern is the limited research
feel enough of a perceived threat to trigger action; conducted to determine the validity of the HBM for
decide that the health benefits outweigh the cost use with women from nonwhite cultural backgrounds
and efforts to overcome the perceived barriers, (McAllister & Farquhar, 1992).
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 55

Background Perceptions Action

Threat Cues to Action

Perceived susceptibility Media
(or acceptance of Personal influence
the diagnosis) Reminders
Perceived severity of
ill-health condition
Factors Behavior to reduce threat
(e.g., education, age, based on expectations
sex, race, ethnicity)
Perceived benefits of
action (minus)
Perceived barriers to
Perceived self-efficacy
to perform action

Figure 3-5 The Health Belief Model.

From Figure 1 The Health Belief Model and HIV Risk Behavior Change (p. 11), by I. M. Rosenstock, V. J. Strecher, & M. H. Becker, in Preventing AIDS: Theories and meth-
ods of behavioral interventions, R. J. DiClemente & J. L. Peterson (Eds.), 1994, New York: Plenum Press. Copyright 1994 by Plenum Press. Reprinted with permission.

Due to concerns regarding the constructs and their for use by interdisciplinary teams. The following
failure to translate to a wellness approach for use example describes such an approach.
with families, Roden revised the HBM (2004a, 2004b).
Two constructsperceived behavioral control (PBC) and Health Belief Model: Health Promotion
behavioral intentionwere added from Ajzens theory of Example
planned behavior (1985). In addition to including these This health promotion example is hypothetical, as
constructs, the revised model also diminishes the influ- actual HBM examples within occupational therapy are
ence of perceived threat, perceived seriousness, and limited (Chen et al., 1999; Kielhofner & Nelson, 1983;
perceived susceptibility by subsuming these constructs Reitz, 1990) and are focused primarily on compliance
under PBC and the perceived notion of health. Cues to with rehabilitation rather than health promotion program
action have been reframed to assist in the models reori- development. In addition to this example, one of the
entation to a health promotion perspective versus an authors real-life applications of the HBMs constructs
illness-prevention focus; this reframing was accom- and principles is described elsewhere in this text. This
plished through a link to the notion of perceived health example, although fictitious, is based on knowledge of
instead of the previous link to the perceived threat of dis- rural health issues and culture gained through partici-
ease (Roden, 2004b). pation in a series of federally supported interdiscipli-
The preceding concerns provide opportunities for nary health promotion activities conducted in western
future research. If these concerns are addressed, both Maryland (Fertman, Dotson, Mazzocco, & Reitz, 2005).
the HBM and Rodens revised model for families These activities were part of a project supported by
(2004a, 2004b) have much to offer health promotion funds from USDHHS, Health Resources and Services
program development and can be used in conjunction Administration, Bureau of Health Professions, and
with occupation-based theories. The NCI (2005) rec- the Quentin N. Burdick Program for Rural Interdisci-
ommended this model for use with health promotion plinary Training, and were directed by the Western
interventions or research that addresses health motiva- Maryland Area Health Education Center in collabora-
tion where the individual or group has a sufficient level tion with various universities.
of perceived susceptibility. If an individual or group Recently, the dominant hand of Ashwood Countys
does not feel they are at risk, this model will not be as star high school football quarterback was amputated by
likely to promote health behavior change. Since the a piece of farm machinery. This accident acted as a cue
HBM has been both used and published by a variety of to action for the county health commissioner and the
health disciplines (Reitz, 1990), it has good potential football coach (who was also the health educator at the
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56 SECTION I Foundations and Key Concepts

countys lone high school). The health commissioner and injury (Thurston, Blundell-Gosselin, & Vollman,
and coach invited various stakeholders, including 2003). They also found that male farmers in Ireland
farmers, school board members, and health providers, had poor health-protective behaviors, with only 18%
to a meeting to design a campaign to address safety on reporting regular dental checks, 26% practicing skin
the farm. Two occupational therapists were invited to protection, and 29% taking regular exercise (Hope,
attend; one works in the school system, and the second Kelleher, Holmes, & Hennessy, 1999, p. 231). Farmers
works at the local hospital (the next closest hospital is in the United States were found to have higher rates
at least a 2-hour drive). At the first meeting, the county of suicide than the general U.S. population, whereas
health commissioner and coach, who are both familiar Canadian farmers suicide rate, with the exception of
with the HBM, suggested this model be used as an Quebec, was at or below that of Canadas general
organizing framework for planning the campaign to population. The supportive tradition of farming commu-
change the individual behaviors of farmers and their nities in Canada was identified as possibly acting as a
families. The model was reviewed with farm safety protective factor (Pickett et al., 2000). It was also noted
committee members. The occupational therapists, who that stress was an ecological problem versus a problem
were knowledgeable of the model from their occupa- of individual farmers (Thurston, Blundell-Gosselin, &
tional therapy education, contributed to the discussion Rose, 2003). This supported the occupational thera-
of the model. As the meeting ended, the committee was pists growing understanding of the need for a compre-
encouraged to prepare for the following meeting by hensive, community-wide, population-based approach
considering campaign ideas and specific ways in which to farmers wellbeing, which would be broader than
they can contribute. this particular event.
The two occupational therapists, both new to the In addition to examining the literature, the occu-
county, decided they must first seek prevalence data on pational therapists also reviewed Healthy People
farm-related injuries and identify possible resources 2010 (USDHHS, 2000) and developed a list of
prior to the next meeting. They decided to meet in health objectives that may relate to farm safety
2 days to compare notes. When they met, they dis- (Table 3-3). In addition, they located a free resource
cussed how farming has been identified as one of the from the NCI (2001), Making Health Communica-
most dangerous occupations in a variety of countries, tion Programs Work, which they ordered by calling
including the United States, in terms of both death 1-800-4CANCER.

Table 33 Examples of Healthy People 2010 Objectives Linked to Farm-Related Injuries

Objective Number Objective

15-1 Reduce hospitalization for nonfatal head injuries.
15-2 Reduce hospitalization for nonfatal spinal cord injuries.
20-1 Reduce deaths from work-related injuries.
20-2 Reduce work-related injuries resulting in medical treatment, lost time from work, or
restricted work injury.
20-3 Reduce the rate of injury and illness cases involving days away from work due to
overexertion or repetitive motion.
20-8 Reduce occupational skin diseases or disorders among full-time workers.
20-11 (Developmental) Reduce new cases of work-related, noise-induced hearing loss.
24-3 Reduce hospital emergency department visits for asthma.
28-8 (Developmental) Reduce occupational eye injury.
28-16 (Developmental) Increase the use of appropriate ear-protection devices, equipment,
and practices.
28-18 (Developmental) Reduce adult hearing loss in the noise-exposed public.

Data from Healthy People 2010: Understanding an improving health, by U.S. Department of Health and Human Services, 2000,
Washington, DC: Government Printing Office.
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 57

In both therapists work settings, they have seen self-efficacy. The Farm Family Safety and Health
evidence of farm injuries among parents and children Workshop Leaders Guide (Indiana Rural Safety &
that mirrored what they found in the literature, even Health Council, n.d.b) was a helpful resource in the
though some of the data had been collected in Canada workshops development.
(Thurston, Bundell-Gosselin, & Vollman, 2003). The Meanwhile, the children who were engaged in
top three reasons for male farmers to seek medical care occupation-based activities that the occupational ther-
included eye injuries, back injuries, and skin problems. apists designed were assisted by high school students
For women, the top two reasons to seek medical care working as part of their required volunteer hours.
were similar to the mens, but the third was general Previously, barriers to participation in health fairs had
muscle and joint injuries (Thurston, Bundell-Gosselin, been work commitments (since farming is often a
& Vollman, 2003). Results of a survey among Arkansas 7-days-per-week job) and lack of childcare. By linking
farmworkers who were still in high school indicated the the health fair to a popular community event and
most common injuries were caused by cuts, falling, removing the barrier of childcare, attendance was
lifting, and animal kicks and bites. Potentially danger- increased. The occupational therapists provided a vari-
ous activities this group frequently engaged in included ety of fun prevention-focused activities for the chil-
use of chainsaws and firearms, handling or feeding dren, including a driving course, complete with orange
large animals, loading equipment, riding on tractors, cones for tricycles and bicycles, which was a minia-
andperhaps most significantlyoperating all-terrain ture version of the course the adults were using for the
vehicles (Hogge, 2002, 10). tractors. Other activities included an obstacle course
Based on the data gathered, the therapists brain- that encouraged physical activities focusing on bal-
stormed to help identify their role on the committee ance and coordination. Modeling the importance of
and arrived at three feasible contributions: breaks when engaging in prolonged physical activity, a
quiet-time coloring activity was provided, using a
1. Create or adapt ready-to-use occupation-based
farm-safety coloring book available in Careful Coun-
activities to increase perceived threat, while
try: Teachers Kit (Indiana Rural Safety & Health
increasing perceived self-efficacy of engage-
Council, n.d.a).
ment in farm safety by farm families.
Other committee members assisted with the rodeo
2. Investigate funding sources to provide seed
and parade activities and coordinated the distribution of
money for the committees work.
donations from businesses supported by the farmers
3. Develop outcome measures to evaluate the
and county residents. A farm equipment distributor
campaign in collaboration with the university
provided safety goggles, lightweight sun-blocking
in the next county.
shirts, and hats. Other businesses contributed food or
The occupational therapists suggested a farm safety goods, such as free samples of sunscreen and water
rodeo, modeled after bicycle safety rodeos in which bottles. After the health fair and driving rodeo activi-
they had participated during their childhood in subur- ties, everyone participated in the homecoming parade.
ban environments. At first the idea was dismissed, but One month after the successful event, the commit-
after continued discussion and lack of an alternative tee reconvened. From discussions with participants,
idea, the high school coach suggested the farm safety including farmers, health providers, and other commit-
rodeo to the homecoming parade organizers. Once the tee members, it was determined that a recommendation
committee members could set the proposed activity would be made for an ongoing regional project to
within their cultural context, suggestions and modifi- address health behavior change both at the individual
cations of the original idea ensued. Through time, the and community levels. Table 3-4 shows theories that
event evolved into a combined health fair and tractor may be of assistance to the committee as they move
rodeo. About 1 year after the original meeting, the from the goal of changing individual farmers health
event was kicked off, beginning with the injured foot- behaviors to engaging in a multicomponent, multilevel
ball player describing his injury and rehabilitation to effort. The next agreed upon step was to invite the
the crowd. According to the HBM, this part of the regional Area Health Education Center (AHEC) staff to
program could become a cue to action for the atten- seek their assistance (National AHEC Organization,
dees and a means to increase perceived threat. Next, 2005) in planning and seeking funding to support a
mini-workshops were held to help the adults address community capacity building initiative (Kretzmann &
perceived susceptibility and the seriousness of farm McKnight, 1993). This initiative would be designed to
injuries, as well as safety features, precautions, address multiple needs of farmers and their neighbors.
and equipment. This information was conveyed in a Community capacity building is described in detail
workshop format to enhance adults perceptions of later in this text.
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58 SECTION I Foundations and Key Concepts

Table 3-4 Using Theory to Plan Multilevel Interventions

Change Examples Ecological Useful Potential Occupational

Strategies of Strategies Level Theories Therapy Theories
Educational Stages of EHP (Establish,
sessions Change or TTM Prevent, Alter)
Change Peoples Interactive kiosks Precaution Adoption MOHO
Behavior Individual Process
Print brochures Health Belief Model OA
Social marketing Theory of Planned PEO
campaigns Behavior PEOP
Change the Media advocacy Communication Theory EHP (Prevent, Create)
Environment campaigns
Advocating Diffusion of Innovations MOHO
changes to Community Community Organizing PEO
company policy
Social Ecological Theory

Adapted from Theory at a glance (2d ed., p. 46), by National Cancer Institute, 2005, Bethesda, MD: National Institutes of Health.
Note: The last column was added by the authors.

PRECEDE-PROCEED Model: assessment of factors in four domains: social, epidemi-

ological, educational and ecological, and administra-
An Overview tive and policy (Green & Kreuter, 2005). It is unique in
The PRECEDE (predisposing, reinforcing, and enabling that it begins with the desired outcome and works back-
constructs in educational diagnosis and evaluation) ward, taking into account factors that must precede a
Model was developed by Green, Kreuter, Deeds, and certain result.
Partridge (1980) and is a planning model for health Phase 1 of this model calls for a social assessment
education and community development. The inclusion and situational analysis (Green & Kreuter, 2005). An
of an additional set of steps, called PROCEED (policy, analysis of the social problems that exist in a commu-
regulatory, and organizational constructions in educa- nity from the inhabitants point of view is a necessary
tional and environmental development), was superim- prerequisite when assessing quality of life in a target
posed on the original model (Green & Kreuter, 1991) population. The purpose of this phase is to ascertain
to promote program evaluation. Through the years, the relationship between a given health problem
the originators have modified the model to keep pace and the social conditions of the community. Phase 2,
with trends in health promotion and public health. For the epidemiological, behavioral, and environmental
example, the language has been changed to better reflect assessment, evaluates health problems associated with
the collaborative process of working with communities the communitys quality of life through objective mea-
in order to determine community assets. More recently, sures. The first step in this process is the collection of
the model has emphasized the importance of genetics by data on vital indicators such as morbidity, mortality,
adding it to Phase 2epidemiological assessmentand fertility, and disability to determine the greatest health
reconfiguring the phases from nine to eight (Green & threats to the community (Green & Kreuter, 1999).
Kreuter, 2005). Table 3-5 identifies the theoretical The second step in Phase 2 is to examine the deter-
underpinnings of this model. minants of health, specifically the genetic, behavioral,
The PRECEDE Model was designed to be readily and environmental factors that impact the health prob-
applicable across a variety of settings. It was intended lems of interest to the population or community. The
to provide structure and organization to health educa- ability to use genetic factors in health promotion
tion program planning and evaluation. Application of planning is expected to improve as the field of applied
this approach occurs in several phases and involves the genetics evolves. Behavior was purposely placed
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 59

Table 35 Diagnostic Elements of PRECEDE-PROCEED

Planning Step Function Example of Relevent Theory

1. Social Assessment Assesses peoples views of their own Community organization
needs and quality of life Community building
2. Epidemiological Assessment Documents which health problems are Community-level theories (if the
most important for which groups in community helps to choose the
a community health problem that will be
3. Behavioral/Environmental Identifies factors that contribute to Interpersonal theories
Assessment the health problem of interest Social Cognitive Theory
Theories of organizational change
Community organization
Diffusion of innovations
4. Educational/Ecological Assessment Identifies preceding and reinforcing All three levels of change
factors that must be in place to initiate theories:
and sustain change Individual
5. Administrative/Policy Assessment Identifies policies, resources, and Community-level theories:
circumstances in the programs context Community organization
that may help or hinder implementation Organization change

From Theory at a glance (2d ed., p. 42), by National Cancer Institute, 2005, Bethesda, MD: National Institutes of Health.

between genetics and environment in the model, intervention. Based on the nature of the targets for inter-
as behaviors are needed to mitigate the influence of vention, educational methodologies are selected (Green
the other two factors (Green & Kreuter, 2005). Mea- & Kreuter, 1999).
sures of behavioral factors can include consumption The fourth and final phase of the PRECEDE process
patterns, utilization rates of services, and self-care is administrative and policy assessment and intervention
patterns. In addition, environmental factors such as alignment (Green & Kreuter, 2005). This phase involves
access, affordability, and equity should be determined an assessment of policies, regulations, and organiza-
when planning a health promotion initiative. Behav- tional factors that impact the implementation of health
ioral and environmental indicators, rated high in promotion programs and the development of strategies
importance and changeability, are usually selected as to effectively manage these influences. Examples
targets for intervention (Green & Kreuter, 1999). include assessment of budgetary implications, identifica-
In Phase 3, educational and ecological assessment, tion and allocation of resources, defining the nature of any
the health-related behaviors and environmental indica- cooperative agreements, and establishing a realistic inter-
tors identified in the previous stage, are differentiated vention timetable. Omission of this important step can
by three categories of influence: predisposing, reinforc- doom an otherwise viable intervention to failure.
ing, and enabling factors. Predisposing factors pro- The PROCEED portion of the model begins with
vide the motivation or rationale for the behaviorfor Phase 5, implementation, and is followed by three
example, knowledge, attitudes, values, and beliefs. additional phases (Green & Kreuter, 1999; 2005) that
Enabling factors promote motivation and include per- focus on evaluation. Phase 6, process evaluation,
sonal skills and assets as well as community resources. occurs as the program unfolds and allows for changes
Predisposing and enabling factors are antecedent to the to be made to address problems before they escalate.
health behavior and allow for the behavior to occur. Community reaction to the program as well as staff per-
Reinforcing factors supply the reward or incentive of formance would be included in this phase of the evalu-
a behavior that contributes to its maintenance. Each ation. Impact evaluation is the focus of Phase 7 and
group of factors is analyzed in terms of importance and measures the immediate effect of the program on the
changeability, and priorities are established for the designated target behaviors. This includes examining the
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60 SECTION I Foundations and Key Concepts

factors from Phase 3 (i.e., predisposing, enabling, and were a success, the committee had identified the need
reinforcing factors). Phase 8, the final phase, focuses on to look beyond their original goal of changing individ-
outcome evaluation. In this phase, long-term changes to ual behaviors of farmers to a broader multilevel initia-
health status and quality of life are measured. tive to include change directed at the environment
through such processes as advocacy and policy devel-
PRECEDE-PROCEED Model: Applicability opment. The need to look beyond the individual farm-
to Health Promotion in Occupational ers to the broader ecological system was supported
Therapy by the literature (Thurston, Blundell-Gosselin, &
The PRECEDE-PROCEED Model has been used in a Rose; 2003; Thurston, Blundell-Gosselin, & Vollman,
variety of settings with different populations, including 2003). After meeting with AHEC representatives, the
committee transformed into a coalition and sought
planning a pedestrian injury prevention program
grant funding to complete a needs assessment using
for children (Howat, Jones, Hall, Cross, &
the PRECEDE-PROCEED framework as a planning
Stevenson, 1997);
tool. Working with the AHECs university partners,
promoting bicycle helmet use among children
funding was received to initiate the PRECEDE ele-
(Stanken, 2000);
ments of the framework and then evaluated using the
preventing computer work-related musculoskeletal
PROCEED portion.
disorders (Wilkens, 2003);
encouraging self-management of asthma among
families in Taiwan (Chiang, Huang, Yeh, & Lu,
2004); Social Ecological Model
identifying factors related to repeat engagement of Health: An Overview
in mammography in underserved women
Ecology is a term used in the biological sciences to
(Ahmed, Fort, Elzey, & Bailey, 2004);
refer to the interrelationships and interactions between
assessing fat intake of low-income mothers
organisms and their environments. Social ecology
(Chang, Brown, Nitzke, & Baumann, 2004);
refers to the study of the influence of the social con-
investigating physicians smoking-cessation coun-
text on behavior, including institutional and cultural
seling (Tremblay et al., 2001); among others.
variables (Sallis & Owen, 2002, p. 462). It describes
This list demonstrates use of this model across a how populations fit into a physical, economical, cul-
variety of populations, health problems, and geo- tural, and social environment that interacts with bio-
graphic settings. According to Green and Kreuter logical substrata (Lemyre & Orpana, 2002, p. 1350).
(2005), 950 articles using the PRECEED-PROCEED Organisms and their environments are made up of
Model have been published. The authors believe the systems, which are organized in levels. The ontosys-
current version of this model, with its educational and tem consists of the individual with his or her unique
ecological approach, is compatible with the aims of a physiological and psychological composition. Humans
recent Institute of Medicine (2002) report on the future develop and are socialized in a microsystem of family
of public health (Green & Kreuter, 2005). Although the and friends. This microsystem is embedded in a
model has many opportunities for application, it is not mesosystem of community, school, work, and reli-
theoretical, as it does not describe the relationships gious organizations. The macrosystem creates social
among the identified factors or variables (Parcel, order through government, law, policy, and public
1984); therefore, it should be used as a planning model services. Social ecology emphasizes the dynamic
rather than a theory to guide research. Nevertheless, it interaction and synergy among the various systems
is a potential tool for an interdisciplinary or community and their components (Lemyre & Orpana, 2002).
team, which may include an occupational therapist or Ecological models of health propose that human
an occupational therapy assistant, to use in addressing behavior is influenced by intrapersonal, physical
a community health concern. environment, and sociocultural factors. Ecological
models focus on environmental causes of behavior
PRECEDE-PROCEED Model: and environmental interventions for health promo-
Health Promotion Example tion. Environmental interventions occur on several
In order to describe the application of the PRECEDE- levels and address intrapersonal, interpersonal, and
PROCEED Model, we will revisit the story of the two community-level issues. Moos (1980) identified four
occupational therapists working in a rural farming categories of health-related environmental factors:
community. Although the health fair and tractor rodeo physical settings, organizational, human aggregate, and
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 61

social climate. Physical settings refer to features of activities occurring at a particular time and place
both the natural and constructed environments. Organi- (Stokols, 1992, p. 10), such as lunchtime at a middle
zational factors refer to the nature, size, and structure school or the impact of food availability on students
of community entities such as schools, hospitals, work- eating patterns. Settings are geographical locations in
sites, and places of worship, among others. The human which various personal or interpersonal situations
aggregate refers to the demographic and sociocultural occur on a regular basis (p. 10), such as worksites
characteristics of people living in a particular area. with excessive environmental stressors that impact the
Social climate refers to the norms, expectations, and workers physical and emotional wellbeing. Life
support of a given social milieu. Moos believed all domains are different spheres of a persons life, such
these factors impact health and health behaviors of as family, education, spiritual activities, recreation,
individuals, families, and communities. employment, and commuting (p. 10). Family life sig-
More recently, Stokols (1992, 1996) described four nificantly impacts health. For example, the presence of
social ecological principles related to health: violence in the home has an extremely detrimental
effect on the wellbeing of family members. Finally,
Health is influenced by physical and social envi-
overall life situation refers to the major life domains
ronmental variables.
in which a person is involved during a particular
Physical and social environments are multidimen-
period of his or her life (p. 10). This is the broadest
and most complex context in which to assess the phys-
Interactions between humans and their environ-
ical and social environmental determinants of health
ments occur at various levels of complexity
(individuals, families, worksite, community, and
Physical and social environments impact health in
population levels).
several ways. Environments can serve as mediums for
Feedback is an essential feature of human-
disease transmission; for example, contamination of
environment interactions, with environments influ-
food sources, airborne diseases, and the interpersonal
encing human behavior and humans influencing
spread of contagions. In addition, the environment
the physical and social features of environments.
can act as a stressor; examples include overexposure
Stokols (1992) suggested a shift in emphasis from to noise, interpersonal conflict, isolation, abrupt
a focus exclusively on individual health habits and economic change, and organizational instability. The
lifestyles to a person-environment-interaction (ecologi- environment is also a source of danger or safety.
cal) approach, combining both behavioral and environ- Dangerous environmental conditions include, but are
mental strategies for health promotion. He advocated for not limited to, natural disasters, pollution, crime, occu-
the development of health-promotive environments, pational hazards, and interpersonal violence. The envi-
which enhance the physical, mental, emotional, and ronment can also function as an enabler of health
social wellbeing of individuals, families, and communi- behavior through the installation of safety devices,
ties. A health-promotive environment is a milieu availability of health-care services, health education,
(Stokols, 1992) that has the following features: and cultural practices that promote health. Finally, the
environment provides health resources, such as clean
injury-resistant, ergonomically sound design of
air and water, sanitation services, and health insurance
physical spaces;
(Stokols, 1992).
nontoxic physical and social environments;
adequate social support networks; Social Ecological Model: Applicability to
economic stability; Health Promotion in Occupational Therapy
organizational flexibility and responsiveness;
Social ecological approaches to health promotion
balance between environmental controllability
have been applied successfully to numerous health
and predictability and novelty and challenge;
problems, including obesity prevention (Egger &
culturally meaningful aesthetic, symbolic, and
Swinburn, 1997), physical activity (CDC, 1999; Sallis,
spiritual elements.
Bowman, & Prat, 1998), violence prevention (Riner &
Environmental influences on health behavior can Saywell, 2002), and substance abuse (Kumpfer &
occur on a small scale (e.g., in a specific situation) or Turner, 1990). Social ecological approaches to health
a larger scale across multiple life domains. Stokols promotion have several core characteristics. They tar-
(1992) identified situations, settings, life domains, and get individual and environmental aspects of health
overall life situation as four levels of environmental behavior and implement multiple intervention strate-
scale. Situations are sequences of individual or group gies across a variety of settings to address a range of
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62 SECTION I Foundations and Key Concepts

Table 36 An Ecological Perspective: Levels of Influence

Concept Definition
Intrapersonal Level Individual characteristics that influence behavior, such as knowledge, attitudes,
beliefs, and personality traits
Interpersonal Level Interpersonal processes and primary groups, including family, friends, and peers
that provide social identity, support, and role definition
Community Level
Institutional factors Rules, regulations, policies, and informal structures, which may constrain or pro-
mote recommended behaviors
Community factors Social networks and norms, or standards, which exist as formal or informal among
individuals, groups, and organizations
Public policy Local, state, and federal policies and laws that regulate or support healthy actions
and practices for disease prevention, early detection, control, and management

From Theory at a glance (2d ed., p. 11), by National Cancer Institute, 2005, Bethesda, MD: National Institutes of Health.

community health problems. Health interventions that reducing fat content of school lunches, increasing
neglect social and physical contextual factors tend to duration of physical activity in physical education
demonstrate high levels of attrition and relapse. Pro- classes, and improving overall nutritional intake and
grams based on social ecological principles promote physical activity behaviors among children (Luepker
healthy lifestyles by creating supportive environments et al., 1996).
(Stokols, Allen, & Bellingham, 1996). Table 3-6 iden-
tifies the key concepts of this approach.
Social Ecological Model: Health Promotion
Transtheoretical Model:
Example An Overview
The Child and Adolescent Trial for Cardiovascular This model is also referred to as the Stages of Change
Health (CATCH) project is an excellent example of a Model (NCI, 2001, 2005). The Transtheoretical Model
health promotion intervention based on social ecologi- (TTM) was originated in the late 1970s and early 1980s.
cal principles. The CATCH project was developed to It is a complex model consisting of stages and processes
address risk factors for cardiovascular disease, includ- of change (DiClemente et al., 1991; Prochaska &
ing serum cholesterol, blood pressure, fat and sodium DiClemente, 1982, 1983, 1992). Prochaska, Norcross,
intake, physical activity, and tobacco use. Consistent and DiClemente (1994) identify the stages of change as:
with the social ecological principle of multilevel inter- precontemplation, contemplation, preparation, action,
vention strategies, CATCH employs approaches that maintenance, and termination. The precontemplation
target individual behavior, family involvement, class- stage refers to the individuals inability to identify that
room curricula, and school policies. The CATCH project they have a problem and as a result, they have no inten-
addresses multiple life contexts and their influence on tion of changing their behavior. In the contemplation
health, and it achieves its outcome of individual behavior stage, the individual can identify and acknowledge a
change both directly, through increasing childrens and problem. They try to understand the problem and are
teens health knowledge, and indirectly, through motivated to do something to remedy the problem.
parental influence and school policies (Grzywacz & The preparation stage is characterized by planning
Fuqua, 2000; Luepker et al., 1996). for change, acquiring needed resources to facilitate
The intervention was evaluated using a random- behavior change, and making public statements about
ized controlled trial with 56 intervention and 400 ones intention to change. The action stage involves
control elementary schools. Over 5000 third graders overtly changing ones behavior, and modifying the
from four states participated in the 3-year project. environment in such a way as to facilitate and maintain
The CATCH intervention demonstrated efficacy in the change. The action stage requires a great deal of
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 63

time, energy, and commitment. The maintenance he moves from the stage of precontemplation of
stage is a long, ongoing process of recommitment to action to contemplation. Cues to action can be instru-
sustaining the behavior change. It is frequently the mental in increasing perceived susceptibility through
most challenging stage in the change process. The raising consciousness. Examples of cues to action
termination stage, the ultimate goal of the change include
cycle, occurs when the behavior change is so well
receiving information on the prevalence of testicular
integrated that there is minimal chance of relapse (Pro-
cancer during a health class;
chaska, Norcross, & DiClemente, 1994). Figure 3-6
seeing a poster in the gym locker room; or
displays the relationship between the various stages,
being provided with a shower card depicting TSE.
while Figure 3-7 depicts the relationships between the
stages and processes. The continued presence of a cue to action, such as a
As can be seen from these figures, together with shower card, encourages self-reevaluation and facili-
constructs from the HBM, for a young man to con- tates movement from contemplation to preparation. In
template a testicular self-examination (TSE), he must addition, increased knowledge about the benefits of
first feel threatened by being at risk for or susceptible early testicular cancer diagnosis through these targeted
to testicular cancer. In addition, he would need to behaviors would favorably impact the mans beliefs
believe it would be a serious matter to be diagnosed regarding outcome expectations. More positive beliefs
with testicular cancer. Once this realization occurs, regarding these practices may, in turn, act as a stimulus
to move from contemplation to preparation.
Continued movement toward engagement in the
desired behavior will be influenced by the ongoing
presence of cues to action and self-efficacy (e.g.,
belief in ability to successfully perform TSE) and by
an ability to complete self-liberating tasks by con-
fronting any remaining interpersonal barriers to per-
forming TSE (e.g., dislike of touching his testicles).
Maintenance As an individual moves from the preparation stage to

action, barriers can have a significant impact on fur-


Precontemplation Contemplation Preparation ther progress. If these barriers are removed, the indi-
vidual can proceed to engagement in the behavior and

ti realize its benefits (e.g., feeling relief from an absence

Precontemplation Contemplation Preparation of lumps and increased self-esteem for taking care of
his health needs). Continued exposure to social sup-
Figure 3-6 A spiral model of the the Stages of Change.
port (i.e., helping relationships), shower cards, and
From In search of how people change: Applications of addictive beaviors by
J. O. Prochaska, C. C. DiClemente, & J. C. Norcross, 1992, American
mass media campaigns will facilitate maintenance of
Psychologist, 47(9), 110214. this behavior.

Text/Image rights not available.

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64 SECTION I Foundations and Key Concepts

Transtheoretical Model: Applicability to boyfriend saw people using when they went rock
Health Promotion in Occupational Therapy climbing the previous weekend. The operative process
Although this model has rarely been discussed in is one of consciousness-raising. In this case, the move-
the occupational therapy health promotion literature, it ment from precontemplation to contemplation could be
recently has been discussed in terms of applicability further facilitated by a grandmother-granddaughter
to chronic pain management (Southam, 2005) and shopping trip to the local outdoor specialty store. (The
substance abuse (Moyers & Stoffel, 1999; Stoffel & grandmother is more willing to take suggestions from
Moyers, 2005). Beyond occupational therapy, it has her granddaughter than her daughter.)
been used widely in efforts to encourage and maintain A few weeks later, the grandmother takes her
health behaviors such as smoking cessation (NCI, 2005), bimonthly trip to the mall. The trip is coordinated by
mammography screening, dietary behaviors, medication the staff at the retirement community where she has
compliance, sun exposure avoidance, unplanned preg- recently moved due to her recurring falls. During the
nancy prevention, reduction or elimination of addictive shopping trip, the grandmother visits an outdoor spe-
behaviors (Prochaska, Redding, & Evers, 2002), and cialty store and tests hiking poles without pressure
physical activity (CDC, 1999; Griffin-Blake & DeJoy, from family members. She determines the poles are
2006). According to McKenzie and colleagues (2005), light enough for her to handle and sufficiently sturdy
the TTM has been useful for health promotion develop- to be of assistance. Within the next few days, the hik-
ers in two key ways: ing poles appear on her birthday wish list and are pur-
chased, thus causing the grandmother to enter the
It emphasizes that not all individuals are ready for preparation stage. The process in action is one of
change right now, regardless if the program is self-reevaluation. Action is achieved when, on her next
available. hiking vacation, she observes younger adults using
It encourages the development of programs to similar poles. She receives positive feedback from her
assist individuals to prepare for change. fellow hikers and found she was better able to keep
pace. She also found her neck to be less sore, as she
The NCI (2001, 2005) included this model in a list felt comfortable returning to her previous hiking pos-
of theories to consider when addressing behavioral ture, rather than constantly trying to monitor the
intentions at the individual level. The NCI identified ground immediately in front of her feet. This served as
this models circular nature as being its strength, reinforcement and began the movement from action to
whereby individuals can enter the change cycle at any maintenance. It is interesting to note that this example
point and repeated attempts to change behavior or also represents constructs from the Model of Human
recycle are possible. Occupation, in terms of volition, habits, and perfor-
Prochaska and colleagues (2002) reported on the mance capacity.
trends in the application of the model. The most
frequent application is identifying the individuals
stage and tailoring intervention to facilitate movement
toward or readiness for the next stage: For example,
Chaos Theory: A Brief Overview
individuals in precontemplation could receive feedback Constructs from this theory are now used and promoted
designed to increase their pros of changing to help by occupational therapy practitioners (Lohman &
them progress to contemplation (Prochaska et al., Royeen, 2002; Royeen, 2003; Royeen & Luebben, 2002)
2002, p. 108). and are considered and debated by other health, social,
and medical sciences (Haigh, 2002; Hudson, 2000;
Transtheoretical Model: Health Promotion Kernick, 2005; Lohman & Royeen, 2002). Particularly
Example relevant constructs for occupational therapy health
This model may be employed to address the use of pro- promotion include self-organization, sensitivity to initial
tective gear during leisure activities to reduce injuries conditions, self-similarity, bifurcations, and others.
and promote safe participation in physical occupations. The ultimate goal of an occupational therapy health
An occupational therapist could use knowledge of this promotion program is self-organization, the ability
model to assist an aging female in deciding to use an of a person, family, or community to use available
assistive device during an upcoming hiking vacation resources to function independently when confronted
after a series of falls, the most recent of which occurred with a challenge or a desire to self-direct evolution.
during an ice storm. Movement from precontemplation The goal of self-organization can be facilitated
to contemplation was facilitated by the granddaughters through interventions that consider additional chaos
discussion of way cool hiking poles she and her theory constructs. Sensitivity to initial conditions
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Chapter 3 Health Behavior Frameworks for Health Promotion Practice 65

means that small differences in input can produce health behavior model should be context driven and,
large differences in output. Small initial errors and where possible, evidence based.
perturbations sometimes endlessly magnify through
positive feedback loops to create major changes
(Hudson, 2000, p. 218). Therefore, it is important to Conclusion
never underestimate the power of small inputs. For Health promotion practice often involves an interdisci-
example, an appropriately timed encouraging gesture plinary team approach wherein the team membership
can have a major therapeutic effect, while a small, does not conform to that of traditional hospital-based
seemingly unnoticed slight can have major negative interdisciplinary teams. Community developers and
repercussions. organizers, community activists, spiritual and reli-
Another construct, self-similarity, is the repeated gious leaders, politicians, public health experts, nutri-
appearance of similar physical characteristics, such tionists, occupational therapists, occupational therapy
as structures in a snowflake or behavioral patterns assistants, physical therapists, art therapists, nurses,
(Hudson, 2000). Occupational roles and habits are and health educators are all examples of potential team
behavioral patterns that evolve but follow a pattern members who may work together on a health promotion
over the life span of a human or community and are initiative. Some of the public health professionals in
important considerations in planning health promo- this group may share a common language that is rep-
tion initiatives. Bifurcations are transition points in resented in the health behavior models that appear in
the development or change in a system over time. As this chapter. In addition, the emerging theories not
a key parameter is increased, key thresholds are commonly associated with health promotion or occu-
reached in which a process splits into two sub- pational therapy introduced in this chapter may also pro-
processes or perhaps alternating rhythms (Hudson, vide important contributions. Hopefully, exposure to
2000, p. 220). At the point of a phase transition or the language of these models and theories, and expo-
bifurcation, the system is functioning on the border sure to the models and theories themselves, will facil-
between order and disorder. It is at this edge of itate interdisciplinary work in health promotion by
chaos where creativity, new business ventures, and occupational therapists and occupational therapy
dramatic change can occur (Elliott, ONeal, & Velde, assistants. Working, writing, and sharing ideas across
2001). Dramatic change is often needed to promote disciplines will assist occupational therapists and
new habits and routines to facilitate a healthy and occupational therapy assistants in gaining the knowl-
quality life. For those instances, this theory and its con- edge necessary to reach their potential in the provision
structs may provide additional guidance in the philo- of health promotion services. They must possess
sophical and theoretical approach to programming. the knowledge and skill to work together with an inter-
Chaos theory and others discussed in this chapter may disciplinary group to effectively enhance the health
provide helpful philosophical guidance regarding the capacity of diverse individuals, families, organizations,
change process necessary for successful occupation- and communities.
based health promotion initiatives.

For Discussion and Review

Selecting and Matching Theories 1. What are the key similarities and differences
Table 3-1 and Table 3-4, which appear earlier in this between the models described in this chapter?
chapter, provide guidance in theory selection for health- 2. Which model (in conjunction with an occupational
promotion efforts. The rightmost column of Table 3-4 therapy model) might assist in the development of a
has been added to the original version of this table preventive, occupation-based intervention for jail or
(NCI, 2005). This additional column includes occupa- prison inmates and their families?
tional therapy theories that may be matched with the 3. Which model described in this chapter would you
identified health behavior models for use at either the select to assist and strengthen an exploratory study
personal or community level. The five occupational of the occupational competency of new parents who
therapy theories described in Chapter 2 of this text are have a history of domestic partner violence? Why
included in this column. The intent of this table is to did you make this selection? Which occupational
serve merely as a guide. Other occupational therapy and therapy model would be appropriate to pair with
health behavior theories also may be applicable for use this model, and why?
in combination or independently. The decision to com- 4. In what ways do the concepts and constructs of
bine theories or select only an occupational therapy or occupational therapy theories overlap with the
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66 SECTION I Foundations and Key Concepts

concepts of the health promotion theories described Becker, M., & Janz, N. (1985). The health belief model applied
in this chapter? to understanding diabetes regimen compliance. Diabetes
Educator, 11, 4147.
5. How do the stages in the transtheoretical model
impact the design of health promotion interventions? Brownson, C. A., & Scaffa, M. E. (2001). Occupational ther-
apy in the promotion of health and the prevention of disease
and disability statement. American Journal of Occupational
Therapy, 55(6), 65660.
Research Questions Buller, D. B., Andersen, P. A., Walkosz, B. J., Scott, M. D.,
1. Which has more impact on the health and the Cutter, G. R., Dignan, M. B., Zarlengo, E. M., Voeks, J. H.,
& Giese, A. J. (2005). Randomized control testing a
healthy occupational engagement in elderly worksite sun protection program in an outdoor recreation
homeless menan occupation-based health industry. Health Education and Behavior, 32(4), 51435.
promotion intervention built on the Model of Centers for Disease Control, National Center for Chronic Disease
Human Occupation and HBM or one built on the Prevention and Health Promotion. (1999). Understanding
Ecology of Human Performance and the Stages and promoting physical activity. Retrieved July 28, 2005,
of Change Model? from http://www.cdc.gov/nccdphp/sgr/chap6.htm.
2. What is the relationship between perceived suscep- Champion, V. (1985). Use of the health belief model in deter-
tibility and adaptation? How do these constructs mining frequency of breast self-examination. Research in
Nursing and Health, 8, 37379.
impact an individuals adoption of joint protection
principles? Chang, M., Brown, R. L., Nitzke, S., & Baumann, L. C. (2004).
Development of an instrument to assess predisposing,
3. How does climate change impact a populations enabling, and reinforcing constructs associated with fat
health, occupational engagement, and social partici- intake behaviors of low-income mothers [research brief].
pation? Journal of Nutrition Behavior and Education, 36, 2734.
4. Which theory or model best explains resiliency in Chen, C-Y, Neufeld, P. S., Feely, C. A., & Skinner, C. S.
children who have experienced trauma? (1999). Factors influencing compliance with home exercise
programs among patients with upper-extremity impairment.
American Journal of Occupational Therapy, 53(2), 17180.
Chiang, L., Huang, J., Yeh, K., & Lu, C. (2004). Effects of a
Acknowledgments self-management asthma educational program in Taiwan
The authors wish to express their appreciation to the based on PRECEDE-PROCEED Model for parents with
asthmatic children. Journal of Asthma, 41(2), 20515.
following individuals who assisted with the preparation
of this chapter: Frederick D. Reitz and Grace Wenger. Cline, R. R., & Worley, M. M. (2006). Osteoporosis health
beliefs and self-care behaviors: An exploratory investiga-
tion. Journal of the American Pharmacists Association,
46(3), 35663.
References DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velcier,
W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process
Ahmed, N. U., Fort, J. G., Elzey, J. D., & Bailey, S. (2004). of smoking cessation: An analysis of precontemplation,
Empowering factors in repeat mammography: Insights from contemplation, and preparation stages of change. Journal of
the stories of underserved women. Journal of Ambulatory Consulting and Clinical Psychology, 59, 295304.
Care Management, 27, 34855. Egger, G., & Swinburn, B. (1997). An ecological approach to
Ajzen, I. (1985). From intentions to actions: A theory of the obesity pandemic. British Medical Journal, 315, 47780.
planned behavior. In J. Kuhl & J. Beckmann (Eds.), Action Elliott, S., ONeal, S. O., & Velde, B. P. (2001). Using chaos
control: From cognition to behavior (pp. 1139). Berlin: theory to understand a community-built occupational ther-
Springer-Verlag. apy practice. Occupational Therapy in Health Care,
Al-Ali, N., & Haddad, L. G. (2004). The effect of the health 13(3/4), 10111.
belief model in explaining exercise participation among Ely, D. P. (1990). Conditions that facilitate the implementation
Jordanian myocardial infarction patients. Journal of of educational technology innovations. Journal of Research
Transcultural Nursing, 15(2), 11421. on Computing in Education, 23(2), 298305.
American Occupational Therapy Association. (2008). Occupa- Fertman, C. I., Dotson, S., Mazzocco, G. O., & Reitz, S. M.
tional therapy practice framework: Domain and processes (2005). Challenges of preparing allied health professionals
(2d ed.). American Journal of Occupational Therapy, for interdisciplinary practice in rural areas. Journal of Allied
26, 62588. Health, 34(3), 16368.
Bardsley, P., & Beckman, L. (1988). The health belief model Glanz, K., Rimer, B. K., & Lewis, F. M. (Eds.). (2005). Health
and entry into alcoholism treatment. International Journal behavior and health education (3d ed.). San Francisco:
of the Addictions, 23, 1928. Jossey-Bass.
Becker, M. H. (1974). The health belief model and sick role Green, L. W., & Kreuter, M. W. (1991). Health promotion
behavior. In M. H. Becker (Ed.), The health belief model planning: An educational and environmental approach
and personal behavior (pp. 8292). Thorofare, NJ: SLACK. (2d ed.). Mountainview, CA: Mayfield.
1193_Ch03_046-069.qxd 6/8/09 5:39 PM Page 67

Chapter 3 Health Behavior Frameworks for Health Promotion Practice 67

Green, L. W., & Kreuter, M. W. (1999). Health promotion (Eds.), Emerging theories in health promotion practice and
planning: An educational and ecological approach (3d ed.). research (pp. 38695). San Francisco: Jossey-Bass.
Mountainview, CA: Mayfield. Kelly, G., Mamon, J., & Scott, J. (1987). Utility of the health
Green, L. W., & Kreuter, M. W. (2005). Health promotion belief model in examining medication compliance among
planning: An educational and ecological approach psychiatric outpatients. Social Science Medicine, 25, 120511.
(4th ed.). New York: McGraw Hill. Kennedy, M. G., & Crosby, R. A. (2002). Prevention marketing:
Green, L. W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. An emerging integrated framework. In R. J. DiClemente,
(1980). Health education planning: A diagnostic approach. R. A. Crosby, & M. C. Kegler (Eds.), Emerging theories in
Palo Alto, CA: Mayfield. health promotion practice and research (pp. 25584).
Griffin-Blake, C. S., & DeJoy, D. M. (2006). Evaluation of San Francisco: Jossey-Bass.
social-cognitive versus stage-matched, self-help physical Kernick, D. (2005). MigraineNew perspectives from chaos
activity interventions at the workplace. American Journal theory. Cephalalgia, 25, 56166.
of Health Promotion, 20(3), 20009. Kielhofner, G., & Nelson, C. (1983). A study of patient motiva-
Grzywacz, J. G., & Fuqua, J. (2000). The social ecology of tion and cooperation/participation in occupational therapy.
health: Leverage points and linkages. Behavioral Medicine, Occupational Therapy Journal of Research, 3, 3546.
26(3), 10115. Kirscht, J. (1974). The health belief model and illness behavior.
Haigh, C. (2002). Using chaos theory: The implications for In M. H. Becker (Ed.), The health belief model and personal
nursing. Journal of Advanced Nursing, 37(5), 46269. health behavior (93105). Thorofare, NJ: SLACK.
Herold, E. (1983). The health belief model: Can it help us Kleier, J. A. (2004). Using the health belief model to reveal the
understand contraceptive use among adolescents? Journal perceptions of Jamaican and Haitian men regarding
of School Health, 53, 1921. prostate cancer. Journal of Multicultural Nursing & Health,
Hester, N., & Macrina, D. (1985). The health belief model and 10(3), 4148.
the contraceptive behavior of college women: Implications Kretzmann, J. P., & McKnight, J. L. (1993). Building commu-
for health education. Journal of American College Health, nities from the inside out: A path toward finding and mobi-
33, 24552. lizing a communitys assets. Evanston, IL: Northwestern
Hogge, A. (2002, August 16). Arkansas study shows: Young University, Center for Urban Affairs and Policy Research.
workers risk injuries on farms. Delta Farm Press, 10. Kumpfer, K. L., & Turner, C. W. (1990). The social ecology
Retrieved July 30, 2005, from http://deltafarmpress.com/ model of adolescent substance abuse: Implications for pre-
mag/farming_arkansas_study_shows/. vention. International Journal of the Addictions, 25(4A),
Hope, A., Kelleher, C., Holmes, L., & Hennessy, T. (1999). 43563.
Health and safety practices among farmers and other Lemyre, L., & Orpana, H. (2002, August). Integrating popula-
workers: A needs assessment. [Abstract]. Occupational tion health into social ecology. Canadian Family Physician,
Medicine, 49(4), 23135. 134951.
Howat, P., Jones, S., Hall, M., Cross, D., & Stevenson, M. (1997). Lohman, H., & Royeen, C. (2002). Posttraumatic stress disor-
The PRECEDE-PROCEED model: Application to planning der and traumatic hand injuries: A neuro-occupational
a child pedestrian injury prevention program. Injury Preven- view. American Journal of Occupational Therapy, 56, 52737.
tion, 3(4), 28287. Luepker, R.V., Perry, C. L., McKinlay, S. M., Nader, P. R., Parcel,
Hudson, C. G. (2000). At the edge of chaos: A new paradigm G. S., Stone, E. J., Webber, L. S., Elder, J. P., Feldman, H. A.,
for social work? Journal of Social Work Education, 36(2), & Johnson, C. C. (1996). Outcomes of a field trial to improve
21531. childrens dietary patterns and physical activity: The Child and
Indiana Rural Safety & Health Council. (n.d.a). Careful country: Adolescent Trial for Cardiovascular Health (CATCH). Journal
Teachers kit. West Lafayette, IN: Author. of the American Medical Association, 275(10), 76876.
Indiana Rural Safety & Health Council. (n.d.b). Farm family Maddux, J. E. (2005). Self-efficacy: The power of believing
safety and health workshop leaders guide. West Lafayette, you can. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of
IN: Author. positive psychology. New York: Oxford University Press.
Institute of Medicine. (2002). Who will keep the public Maiman, L., & Becker, M. (1974). The health belief model:
healthy? Educating public health professionals for the 21st Origins and correlates in psychological theory. In M. Becker
century. Washington, DC: National Academy of Sciences. (Ed.), The health belief model and personal health behavior.
Thorofare, NJ: SLACK.
Juniper, K. C., Oman, R. R., Hamm. R. M., & Kerby, D. S.
(2004). The relationships among constructs in the health Mandel, D., Jackson, J. M., Zemke, R., Nelson, L., & Clark,
belief model and the transtheoretical model among African- F. A. (1999). Lifestyle redesign: Implementing the well
American college women for physical activity. American elderly program. Bethesda, MD: American Occupational
Journal of Health Promotion, 3, 35457 Therapy Association.
Kegeles, S., & Lund, A. (1982). Adolescents health beliefs and McAllister, G., & Farquhar, M. (1992). Health beliefs: A cul-
acceptance of a novel preventive dental activity: Replication tural division. Journal of Advanced Nursing, 17, 144754.
and extension. Health Education Quarterly, 9, 96112. McKenzie, J. F., Neiger, B. L., & Smeltzer, J. L. (2005).
Kegler, M. C., Crosby, R. A., & DiClemente, R. J. (2002). Planning, implementing, and evaluating health promotion
Reflections on emerging theories in health promotion prac- programs: A primer (4th ed.). Needham Heights, MA:
tice. In R. J. DiClemente, R. A. Crosby, & M. C. Kegler Allyn & Bacon.
1193_Ch03_046-069.qxd 6/8/09 5:39 PM Page 68

68 SECTION I Foundations and Key Concepts

Melnyk, K. A. M. (2005). Barriers: A critical review of recent Reitz, S. M. (1992). A historical review of occupational ther-
literature. Nursing Research, 37(4), 196201. apys role in preventive health and wellness. American
Moos, R. H. (1980). Social-ecological perspectives on health. Journal of Occupational Therapy, 46, 5055.
In G. C. Cohen, F. Cohen, & N. E. Adler (Eds.), Health Reitz, S. T. (1990). The health belief model: An overlooked
psychology: A handbook. San Francisco: Jossey-Bass. tool for occupational therapy? Physical Disabilities SIS
Moyers, P. A., & Stoffel, V. C. (1999). Case reportAlcohol Newsletter, 13(11), 14.
dependence in a client with a work-related injury. American Reno, D. (1988). Mens knowledge and health beliefs about
Journal of Occupational Therapy, 53(6), 64045. testicular cancer and testicular self-examination. Cancer
National AHEC Organization. (2005). Area Health Education Nursing, 11(2), 11217.
Center (AHEC) program. Retrieved July 30, 2005, from Riner, M. E., & Saywell, R. M. (2002). Development of the
http://www.nationalahec.org/main/ahec.asp. social ecology model of adolescent interpersonal violence
National Cancer Institute. (2001). Making health communica- prevention. Journal of School Health, 72(2), 6570.
tion programs work: A planners guide. Bethesda, MD: Roden, J. (2004a). Revisiting the Health Belief Model: Nurses
National Institutes of Health. (Reprinted 2004). applying it to young families and their health promotion
National Cancer Institute. (2005). Theory at a glance (2d ed.). needs. Nursing & Health Sciences, 6(4), 110.
Bethesda, MD: National Institutes of Health. Retrieved Roden, J. (2004b). Validating the revised Health Belief Model
March 3, 2007, from http://www.cancer.gov/theory.pdf. for young families: Implications for nurses health promo-
Oldenburg, B., & Parcel, G. S. (2002). Diffusion of innovations. tion practice. Nursing & Health Sciences, 6(4), 24759.
In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health Rogers, E. M. (1995). Diffusion of innovations (4th ed.).
behavior and health education: Theory, research, and prac- New York: Free Press.
tice (3d ed., pp. 31234). San Francisco: Jossey-Bass. Rogers, E. M. (2003). Diffusion of innovations (5th ed.).
Parcel, G. S. (1984). Theoretical models for application in New York: Free Press.
school health education research. Special combined issue of Rosenstock, I. (1966). Why people use health services.
Journal of School Health, 54, 3949 and Health Education, Milbank Quarterly, 44(3), 94124.
15, 3949.
Rosenstock, I. (1974). Historical origins of the Health Belief
Paulk, M. C. (1999). Structured approaches to managing Model. In M. Becker (Ed.), The Health Belief Model and
change. Retrieved March 10, 2007, from personal behavior. Thorofare, NJ: SLACK.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1994). The
Pickett, W., King, W. D., Faelker, T., Lees, R., Morrison, H. I., Health Belief Model and HIV risk behavior change. In
& Bienefeld, M. (2000). Suicides among Canadian farm R. J. DiClemente & J. L. Peterson (Eds.), Preventing AIDS:
operators. Chronic Diseases in Canada, 20(3), 110. Theories and methods for behavioral interventions
Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical (pp. 524). New York: Plenum Press.
therapy: Toward a more integrative model of change. Psy- Royeen, C. B. (2003). Chaotic occupational therapy: Collective
chotherapy: Theory, Research and Practice, 19(3), 27688. wisdom for a complex profession, 2003 Eleanor Clarke
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and Slagle Lecture. American Journal of Occupational Therapy,
processes of self-change of smoking: Toward an integrative 57, 60924.
model of change. Journal of Counseling and Clinical Royeen, C. B., & Luebben, A. J. (2002). Annotated bibliography
Psychology, 51(3), 39095. of chaos for occupational therapy. Occupational Therapy in
Prochaska, J. O., & DiClemente, C. C. (1992). Stages of Health Care, 16(1), 6380.
change in the modification of behavior problems. In Sallis, J. F., Bauman, A., & Pratt, M. (1998). Environmental
M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress and policy interventions to promote physical activity.
in behavior modification (pp. 184214). Sycamore, IL: American Journal of Preventive Medicine, 15, 37997.
Sycamore Press.
Sallis, J. F., & Owen, N. (2002). Ecological models of health
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). behavior. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.),
In search of how people change: Applications of addictive Health behavior and health education: Theory, research
behaviors. American Psychologist, 47(9), 110214. and practice. San Francisco: Jossey-Bass.
Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Scaffa, M. E., Van Slyke, N., & Brownson, C. A. (2008). Occu-
Changing for good: A revolutionary six-stage program for pational therapy services in the promotion of health and the
overcoming bad habits and moving your life positively for- prevention of disease and disability. American Journal of
ward. New York: HarperCollins. Occupational Therapy 62(6), 694703.
Prochaska, J. O., Johnson, S., & Lee, P. (1998). The transtheo- Southam, M. (2005). Psychosocial aspects of chronic pain. In
retical model of behavior change. In S. A. Shumaker, E. Cara & A. MacRae (Eds.), Psychosocial occupational
E. B. Schron, J. K. Ockene, & W. L. McBee (Eds.), The therapy (2d ed., pp. 42345). Clifton Park, NY: Thomson.
handbook of health behavior change (2d ed., pp. 5984).
New York: Springer Publishing. Stanken, B. A. (2000). Promoting helmet use among children.
Journal of Community Health Nursing, 17(2), 8592.
Prochaska J. O., Redding, C. A., & Evers, K. (2002). The
transtheoretical model and stages of change. In K. Glanz, Stoffel, V. C., & Moyers, P. A. (2005). Occupational therapy
B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and and substance use disorders. In E. Cara & A. MacRae
health education: Theory, research, and practice (3d ed., (Eds.), Psychosocial occupational therapy (2d ed.,
99120). San Francisco: Jossey-Bass. pp. 44673). Clifton Park, NY: Thomson.
1193_Ch03_046-069.qxd 6/8/09 5:39 PM Page 69

Chapter 3 Health Behavior Frameworks for Health Promotion Practice 69

Stokols, D. (1992). Establishing and maintaining health smoking: An intervention program to optimize smoking
environments: Toward a social ecology of health promotion. cessation counseling by Montreal general practitioners.
American Psychologist, 47(1), 622. Canadian Medical Association Journal, 165(5), 60107.
Stokols, D. (1996). Translating social ecological theory into Turner, L. W., Hunt, S. B., DiBrezzo, R., & Jones, C. (2004).
guidelines for community health promotion. American Design and implementation of an Osteoporosis Prevention
Journal of Health Promotion, 10(4), 28298. Program using the Health Belief Model. American Journal
Stokols, D., Allen, J, & Bellingham, R. L. (1996). The social of Health Studies, 19(2), 11521.
ecology of health promotion: Implications for research and U.S. Department of Health and Human Services. (2000).
practice. American Journal of Health Promotion, 10(4), Healthy People 2010: Understanding and improving health
24751. (2d ed.). Washington, DC: U.S. Government Printing Office.
Thurston, W. E., Blundell-Gosselin, H. J., & Rose, S. (2003). White, M. C., Tulsky, J. P., Menendez, E., Arai, S., Goldenson,
Stress in male and female farmers: An ecological rather J., & Kawamura, L. M. (2005). Improving tuberculosis
than an individual problem. Canadian Journal of Rural therapy completion after jail: Translation of research to
Medicine, 8(4), 24754. practice. Health Education Research, 20(2), 16374.
Thurston, W. E., Blundell-Gosselin, H. J., & Vollman, A. R. Wilkens, P. M. (2003). Preventing work-related musculoskele-
(2003). Health concerns of male and female farmers: tal disorders in VDT users: A comprehensive health
Implications for health promotion. Canadian Journal of promotion program. Work, 20, 17178.
Rural Medicine, 8(4), 23946.
Tremblay, M., Gervais, A., Lacroix, C., OLoughlin, J., Makni,
H., & Paradis, G. (2001). Physicians taking action against
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Chapter 4

Public Health Principles,

Approaches, and Initiatives
S. Maggie Reitz and Marjorie E. Scaffa

Many of the improvements in personal health over the last century can be directly traced
to public health efforts. While occupational and physical therapists have not traditionally
performed in public health activities, the sedentary nature of American society and the
increasing incidence of chronic disease and disability is challenging them to become
involved in public health efforts.
Sandstrom, Lohman, & Bramble, 2003, p. 252

Learning Objectives
This chapter is designed to enable the reader to:
Identify public health constructs and principles, Therapy Practice Framework: Domain and Proc-
policies, approaches, and initiatives that support esses (referred to as the Framework; American
occupation-based health promotion programs. Occupational Therapy Association [AOTA], 2008)
Describe the relationships among U.S. public Describe key domestic and international govern-
health, the new public health, community health, mental and organizational reports and policies
health promotion, prevention, wellness, and occu- that support national and global health promotion.
pational therapy. Utilize national and state-level documents and
Discuss the role of occupational therapy in public objectives to support occupation-based preventive
health using the language of the Occupational programming for populations.

K e y Te r m s
Community health Healthy community Occupational justice Wellness
Health New Freedom Initiative Prevention World Health Organiza-
Health-care disparities (NFI) Preventive occupation tion (WHO)
Health promotion New public health Public health

and enforcing health-protecting laws and regulations,

Introduction implementing and evaluating population based strate-
Public health is what a society does collectively to gies to promote health and prevent disease, and assur-
facilitate conditions that enable its members to be healthy ing the provision of essential health services. (Lasker
(Institute of Medicine [IOM], 1988). Traditionally, pub- & the Committee on Medicine and Public Health,
lic health has been defined as health of populations and 1997, p. 3)
communities (Tulchinsky & Varavikova, 2000, p. 2). It
In the United States, the public health system has
differs from medicine in that it focuses on facilitating
been shaped by scientific knowledge and prevailing
health and wellbeing of populations by
societal values. It also has been greatly influenced by
assessing and monitoring health problems, informing the health initiatives and policy development in Great
public and professionals about health issues, developing Britain and Canada. The United States has been
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Chapter 4 Public Health Principles, Approaches, and Initiatives 71

involved in international public health initiatives through around the solutions (IOM, 1988, p. 70). The history of
its participation in the World Health Organization public health in the United States mirrors this descrip-
(WHO) since that organizations inception in 1948 tion, beginning with the areas original inhabitants. The
(WHO, 1948). The WHO is the United Nations spe- indigenous peoples of the Americas had an appreciation
cialized agency for health. It is comprised of 192 mem- for hygiene and sanitation procedures, which helped
ber states that work toward the attainment by all peoples maintain health and prevent disease. Early visitors from
of the highest possible level of health (WHO, 2005a, 1). Europe noted the frequency of bathing habits and the
In 2000, the United Nations set eight broad goals, known cleanliness of homes and public areas among this popu-
as the Millennium Development Goals (MDGs), to lation (Vogel, 1970). Appendix A identifies key histori-
achieve by 2015. Three of these goalsto reduce child cal events in public health and health care, nationally and
deaths; improve maternal health; and combat HIV/ internationally, over the last several hundred years.
AIDS, malaria, and other diseasesare directly related In the 18th century, the solution for the public health
to health and fall under the purview of the WHO. Two problem of infectious disease was the institution of
other MDGsto eradicate extreme hunger and poverty isolation techniques and quarantine. Hospitals were
and to achieve environmental sustainabilityhave the built to isolate and treat the ill. Voluntary general
potential to significantly impact health. hospitals were established for those with physical
The WHO has four current priorities: illnesses, and public institutions for the care of the men-
tally ill were founded (IOM, 1988, p. 57). The first pub-
Ensuring global health security by identifying
lic mental health hospital in British North America was
emerging threats to health and managing them
built in Williamsburg, Virginia, in 1773 (IOM, 1988;
Zwelling, 1985). This Public Hospital for Persons of
Reducing tobacco use and promoting healthy
Insane and Disordered Minds was built in an underde-
nutrition and physical activity to decrease the
veloped area on the towns border. Before the hospital
incidence of chronic diseases
was built, individuals with mental health problems were
Increasing efforts to support the achievement of
housed in the public jail, which was a common practice
the MDGs
in North America at that time (Zwelling, 1985).
Improving health-care services, including fair
Moral treatment, a new strategy for the care of indi-
access for all (WHO, 2006a)
viduals with mental illness, was initiated in the United
After providing a brief history of the public health in States in the 19th century, based on the successes of
the United States, this chapter will describe the new pub- Pinel in France and Tuke in England (Peloquin, 1989).
lic health; review terminology; and summarize current In his work Medical Philosophical Treatise on Mental
governmental documents and initiatives, such as Healthy Alienation (1948), Pinel provided examples of and praise
People 2010 (U.S. Department of Health and Human for the use of moral treatment at an asylum in Saragross,
Services [USDHHS], 2000a). The implications of these Spain, and another in Amsterdam, Netherlands.
reports for occupational therapy practice and the promo- In 1817, the Friends Asylum, the first hospital
tion of occupational justice will be detailed in an addi- founded in the United States to provide moral treat-
tional feature called Implications for Occupational ment, was built in Philadelphia. Peloquin presented a
Therapy that was added especially for this chapter. This variety of descriptions and views of moral treatment
feature was designed to assist the reader in applying and from them distilled an image of moral treatment as
various documents, principles, and approaches with a humane treatment, a routine of work and recreation,
public health focus to occupational therapy interven- an appeal to reason, and the development of desirable
tions. The role of occupational therapy assistants and moral traits (1989, p. 538). Documented success rates
occupational therapists within interdisciplinary public using this technique at both private asylums and public
health initiatives and the relationship between public hospitals were impressive, with reported recovery rates
health, new public health, occupational therapy, health of over 70% (Peloquin, 1989).
promotion, and wellness will also be explored. The Moral Management Era was eventually embraced
at the Public Hospital for Persons of Insane and Disor-
dered Minds in Williamsburg, where it flourished from
History of Public Health 1836 to 1862 (Colonial Williamsburg Foundation, 2004)
under the management of Alexander Galt and then his
in the United States son John Galt II (Zwelling, 1985). John Galt instituted an
The history of public health has been one of identifying extensive program of occupations, including a carpentry
health problems, developing knowledge and expertise to shop, sewing, spinning, and weaving rooms, a shoemak-
solve problems, and rallying political and social support ing shop, patient library, a game room, and a variety of
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72 SECTION I Foundations and Key Concepts

occupations performed in the hospital garden and wood all [the new public health] stresses that both society and
yard (Zwelling, 1985, p. 32). In addition, he supplied the individual have rights and responsibilities in promot-
patients with musical instruments and organized exten- ing and maintaining health through direct services and
sive social activities, such as lectures and concerts and through healthy environmental and community health
scheduled carriage rides about town for female promotion (Tulchinsky & Va avikova, 2000, p. 3).
patients (Zwelling, 1985, pp. 3233). Galt also worked This new public health paradigm supported the
to ensure the environment was as comfortable and attrac- continued development of local and state health depart-
tive as possible. Pleasing furniture, wall hangings, table ments and increased governmental involvement in pub-
settings, and the use of flowers are examples of Galts lic and personal health (IOM, 1988). The Centers for
efforts to make hospital life less Spartan and sterile. Disease Control and Prevention (1999) identified
These efforts were consistent with Galts overall treat- the top 10 achievements in public health in the 20th
ment strategy, which was to emphasize the patients san- century: vaccinations to prevent disease, increased
ity rather than their insanity (Zwelling, 1985, p. 34). motor vehicle safety, safer and healthier workplaces,
The potential for moral treatment in the United improved control of infectious diseases, decline in
States was curtailed by the Civil War (Peloquin, 1989; deaths from stroke and coronary heart disease, safer
Zwelling, 1985) and the economic and social crises that and healthier foods, healthier mothers and infants,
ensued. The success of moral treatment encouraged a advances in family planning, fluoridation of drinking
push for equal access to treatment by social reformers. water, and recognition of the health hazards of tobacco.
Although the effort to gain equal access was success- However, near the end of the 20th century, a fiscal crisis
ful, insufficient planning and funding resulted in severe significantly decreased available resources for problem-
overcrowding, which led to custodial care replacing solving and implementing public health initiatives.
curative moral treatment (Kielhofner, 2004; Peloquin, This financial crisis was one of the factors leading to
1989). This, together with the greater emphasis on the disarray of public health and the establishment of
biological causes and cures of disease, reduced interest the Committee for the Study of the Future of Public
in both public health and the behavioral and environ- Health. The committee was charged with developing
mental factors associated with mental illness. Dunton, recommendations to facilitate the mission of public
one of the founders of occupational therapy, believed health in the United States, thereby assuring condi-
that moral treatment reemerged years later in the form tions in which people can be healthy (IOM, 1988,
of occupational therapy (Schwartz, 2003). p. 140). Although the problems addressed by U.S. pub-
The problems of infectious disease and mental ill- lic health practitioners have changed in volume and
ness continued as a focus of public health into the complexity since the 18th century, the focus remains on
19th century, with new public health strategies evolving finding solutions to current population-based health
based on the current science of the period. An emphasis problems, identifying interventions to prevent the
on sanitation and hygiene developed as a result of development and spread of illness, and addressing
advances in bacteriology. New strategies required labo- behaviors that impact the health of society. The general
ratories, which provided the impetus for the develop- goals of public health in the 21st century are to
ment of local and state health departments (IOM, 1988).
prevent epidemics and minimize the spread of
Maps became public health tools as the impact on sani-
tation and public health of the physical structures within
protect against environmental hazards;
cities (e.g., streets, rivers, drains) was recognized.
prevent injuries;
The new public health emerged in the early 20th
promote health behaviors;
century when public health increasingly focused its
respond to disasters and assist communities in
attention on health education, maternal and child health,
and the detection of unrecognized but treatable impair-
assure access to health services; and
ments (Lasker & the Committee on Medicine and
enhance quality of life (USDHHS, 1994, 1).
Public Health, 1997, p. 15). The new public health
addressed both interventions and preventive strategies
to promote the health and wellbeing of populations, Relationship Between Public Health
communities, and individualsincluding equitable and Medicine
access to services (Goraya & Scambler, 1998; Roemer, At the inception of the U.S. Public Health Service
2000; Tulchinsky & Varavikova, 2000). The Ottawa in 1798 (Timmreck, 1995), there was a close relationship
Conference and the resultant Ottawa Charter for Health between leaders in public heath and medicine.
Promotion (WHO, 1986) have been identified as the This positive working relationship lasted until the early
catalyst for a paradigm shift in public health to a focus 20th century (Lasker et al., 1997). The two disciplines
on policy (OConnor-Fleming & Parker, 1995): Above shared a goal of addressing the most significant health
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Chapter 4 Public Health Principles, Approaches, and Initiatives 73

threat of the timeinfectious disease. Fighting this com- some occupational therapy services may include health
mon enemy encouraged cooperation between public promotion activities at a basic level, the potential
health and medicine. However, advances in bacteriology to broaden the scope of practice to address the new
and other sciences decreased the threat of infectious dis- public health needs of the United States and the global
eases, and a division between medicine and public heath community exists. In order for this increase in scope
emerged. This divide accelerated after World War II due to occur, it is essential to understand what health
to differences in funding and training. Limited incentives promotion is and is not and its relationship to interven-
existed for collaboration in education, resulting in little to tions at the individual, family, community, and societal
no cooperative teaching. These factors tended to facilitate level. This understanding requires familiarity with
recurring tensions deriving from overlapping interests key terms.
and the development of striking cultural differences The most often cited definition of health is the
between the two fields (Lasker et al., 1997, p. 1). complete state of physical, mental, and social wellbe-
The divide, although narrowed, continues to exist ing, and not just the absence of disease or infirmity
today. As in the past, opportunities to enhance the (WHO, 1947, p. 29). Although this definition has
nations health through collaboration have been missed remained consistent since 1947, there has been a grow-
(Lasker et al., 1997), but examples of cooperation ing appreciation that health is a resource for every-
remain. The Robert Wood Johnson Foundation com- day life and dependent upon other resources (WHO,
missioned a study to determine factors facilitating 1986, p. 1). Content Box 4-1 displays the prerequisites
the division between medicine and public health and for health identified by WHO (1986) in the Ottawa
what could be done to foster positive collaboration. The Charter for Health Promotion.
New York Academy of Medicine (NYAM) was respon- Unlike the definition of the term health, the concept
sible for completing this study, whose timing was well of health promotion has evolved over time and setting,
matched to the growing realization of leaders in both resulting in the existence of a variety of definitions for
disciplines that each could benefit from a closer work- the term health promotion. The WHO (1986; 1997a,
ing relationship. The formation of the Medicine/Public p. 1) described it broadly as the process of enabling
Health Initiative, a joint project between the two disci- people to increase control over, and to improve,
plines in 1996 (Reiser, 1997), had already begun to health. Green and Kreuter (1999) suggested that
pave the way for success. Through the course of the health promotion is any combination of educational
NYAMs work, 414 cases of successful collaboration and ecological supports for action and conditions of
were gathered and reviewed. living conducive to health (p. 112). The WHO (1997a)
Another example of the collaboration between pub- believes health promotion has the potential for making
lic health, medicine, and other disciplines is the pro- the greatest impact on improved health status and
duction of governmental reports and policies. Positive social justice.
results are obtained when various practitioners, includ- One way occupational therapists and occupational
ing occupational therapists and occupational therapy therapy assistants can improve health status and social
assistants, collaborate to provide population-based justice is by maximizing the health and wellbeing of
health promotion. Several key governmental reports communities. A variety of definitions exist for the term
will be described, which are significant for occupa- community health. The definition that best captures
tional therapists and occupational therapy assistants the philosophy of the occupational therapy profession
interested in program development and for those seek-
ing funding and advocating for health policy. These
documents are introduced after presenting relevant ter-
minology and a description of occupational therapys
role within the new public health arena. Content Box 4-1

Prerequisites for Health

Terminology and the Role Peace
of Occupational Therapy Shelter
in the New Public Health Food
While a growing trend exists in occupational therapy Stable eco-system
practice toward community-based practice and some Sustainable resources
movement has been observed toward population-based Social justice and equity
interventions, most interventions are still aimed at and From Ottawa charter for health promotion (p. 1), by World Health
delivered to individuals (Wilcock, 2003). Although Organization, 1986, Geneva, Switzerland.
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74 SECTION I Foundations and Key Concepts

has been posed by Scaffa, Desmond, and Brownson strategy of reaction to a strategy of precaution.
(2001): Community health refers to the physical, Together with related approaches such as health impact
emotional, social, and spiritual wellbeing of a group of assessment, precaution provides a useful means of
people linked together in some way, possibly through guiding public health decisions under conditions of
geographical proximity or shared interests (pp. 3940). uncertainty, in a manner that appropriately addresses
This definition is consistent with the AOTA (2008) the issues of power, ownership, equity and dignity.
Framework. Occupational therapy can assist in the (WHO, 2004b, p. 3)
promotion of health in a community of stroke survivors,
The term wellness is used frequently in conjunction
small towns, college campuses, refugee camps, city
with health promotion. Wellness has been defined as
boroughs, or a variety of other communities.
a dynamic way of life that involves action, values,
A primary goal of community health and health
and attitudes that support or improve health and
promotion is the prevention of disability, injury, and
quality of life (Brownson & Scaffa, 2001, p. 656).
disease. Prevention has been defined in AOTAs Frame-
Figure 4-1 depicts the role of occupational therapy in
work (2008, p. 674) as promoting a healthy lifestyle
new public health, where the target of the intervention
at the individual, group, organizational, community
is a society as a whole or a broad population within
(societal), governmental/policy level (adapted from
that society. In order for occupational therapy public
Brownson & Scaffa, 2001). Typically, prevention is
health interventions to realize their potential benefit to
classified into three levels: primary, secondary, and
individuals, families, communities, and society, these
tertiary. These levels are defined in Table 4-1. Examples
interventions must
of activities for each of these prevention levels are
detailed in Table 4-1 and in Figure 1-6 of Chapter 1 of be planned, delivered, and evaluated through
this text. The WHO recognizes the increasing complex- active engagement with the population, in order
ity of identifying risk factors for prevention and advo- to maximize ownership by the population; and must
cates for a broader perspective and approach, one include participation in health-enhancing occupa-
focused on precautionary principles: tions by the individual, family, community, or
The concepts of precaution and prevention have
always been at the heart of public health practice. Public Health promotion is the primary tool used by occupa-
health is inherently about identifying and avoiding risk tional therapists and occupational therapy assistants in
to the health of populations, as well as about identify- public health. It includes education strategies, advocacy,
ing and implementing protective measures. In the past, and other preventive interventions. Occupation-based
public health interventions focused on removing haz- health promotion is the process used by practitioners to
ards that had already been identified and proven assist individuals, families, communities, or society in the
(even if the etiological mechanisms were not well pursuit of occupational wellness. These efforts are sup-
understood). As modern potential risk factors ported by and consistent with the language and descrip-
become more complex and far-reaching, the precau- tion of the domain of occupational therapy and the process
tionary principle addresses uncertain risks and seeks to of service delivery in the AOTA Framework (2008). For
shift the ways in which science informs policy from a example, whether a health promotion intervention is

Table 41 Definitions of Levels of Prevention and Examples

Term Definition Examples

Primary prevention Interventions with healthy individuals, communities, Lifestyle redesign
and populations in order to decrease risk for potential Falls prevention
health problems
Secondary prevention Early detection and treatment of diseases or disabilities Developmental
Tertiary prevention Interventions with people with disabilities or traumatized Joint protection
communities to prevent or minimize further dysfunction Hurricane relief

Data from Public health, community health, and occupational therapy by M. E. Scaffa, S. Desmond, & C. A. Brownson in Occupational therapy
in community-based settings, 2001, Philadelphia: F. A. Davis.
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Chapter 4 Public Health Principles, Approaches, and Initiatives 75

[Owned by the
Individual, Family,
Community, & Society]
(the outcome)

l l -B nal
We ati
c ing ccup and ce
n sti
ha h O on
En oug ptati al Ju
h r a n
Health Promotion T Ad atio
c up
Interventions Oc
[Delivered by the
Therapy Practitioner]
(the process)

Figure 4-1 Occupational therapys role in the new public health through occupation-based health promotion.
Courtesy of Reitz, Scaffa, & Pizzi (2004) used by S. M. Reitz in Health and wellness through occupation: The American perspective, invited open seminar, Hospital
Authority, Hong Kong, February 27, 2004.

aimed at an individual, family, community, or population, MoveTM (Partnership to Promote Healthy Eating and
the first step is to complete an occupational profile. This Active Living [PPHEAL], 2003), Healthy Campus
profile would be followed by an occupational perfor- 2010: Making It Happen (American College Health
mance analysis of the individual, family, or community Association [ACHA], 2002), and bike helmet laws
population, which, with the clients feedback, would be and helmet distribution programs.
used in the development of an occupation-based interven-
tion. Examples of assessments that can be used to conduct
an occupational profile of a community or population are International Official
described in Chapter 10. One possible type of intervention
would be an interdisciplinary community-led effort to Health Promotion
promote occupational justice through advocacy and Documents and Initiatives
capacity building, with the outcome being enhanced com-
A variety of international documents and those from
munity health and occupational engagement.
other nations provide guidance in the development of
The majority of occupation-based health promotion
health promotion policies and interventions. Five of
interventions in the United States are currently tar-
these documents will be described below, including
geted toward the specific needs of an individual client
(as is the case with most occupational therapy inter- A New Perspective on the Health of Canadians
ventions). When efforts are aimed at a population, (Lalonde, 1974);
they are considered public health interventions. If Ottawa Charter for Health Promotion (WHO,
these interventions are simultaneously aimed at 1986);
decreasing occupational deprivation and occupational Jakarta Declaration on Leading Health Promotion
alienation at the societal level, they are consistent into the 21st Century (WHO, 1997a);
with the values of the new public health. Public health International Classification of Functioning,
is an interdisciplinary activity; thus, occupation-based Disability, and Health (WHO, 2001); and
public health initiatives must be conducted as part of Twenty Steps for Developing a Healthy Cities
a broader interdisciplinary program or movement. Project (WHO, 1997b).
Figure 4-2 displays three examples of the possible
relationships between policy (at the local, state, and A New Perspective on the Health
national level), governmental agencies, governmental of Canadians
reports, interdisciplinary public health programming, This document, often referred to as the Lalonde
and target populations. The lines indicate the relation- Report published in 1974, was the first definitive gov-
ships for each of the three examples: America on the ernmental report to outline a vision for the future
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76 SECTION I Foundations and Key Concepts

Influences Health Policy Facilitators Intervention Target
Influences Examples

National Health Federal Agencies

Agenda and (e.g., USDHHS, America on Nation
Health Objectives USDOT) The MoveTM

U.S. Societal Influences (e.g., independence, fads, litigation)




Academia 2010
National Policy


State Health State Health

Agendas and Agencies Bike Family
State Policy Helmet
Laws &
Local Health
Local Policy Distribution Individuals

Figure 4-2 Health promotion policy in action.

Courtesy of Reitz, Scaffa, & Merryman (2004). Examples of Health Promotion Programming in the U.S. [Figure]. Used by S. M. Reitz in Occupational therapy in health
promotionMoving into a new era, invited plenary session, Occupational Therapy Symposium 2004Achieving Health and Wellness Through Occupation: From Theory
to Practice, Hong Kong, February 28, 2004.

health of its citizens using a planning-by-objectives services, which is inconsistent with public health val-
approach. Other countries used the Lalonde Report ues (Tulchinsky & Varavikova, 2000).
and then the U.S. governments 1979 Healthy Peo-
ple: The Surgeon Generals Report on Health Ottawa Charter for Health Promotion
Promotion and Disease Prevention and the WHOs This document was developed in 1986 at the First
Primary Health Care for All initiatives as models International Conference on Health Promotion (Green
for this approach (Green & Kreuter, 1999). Health & Kreuter, 1999; Tulchinsky & Varavikova, 2000). The
was identified in the Lalonde Report as being depen- preparation of this document resulted in a shift in focus
dent on the interaction of human biology, now from lifestyle or proximal risk factors to risk conditions
referred to as genetics, the environment, lifestyle, and and broader determinants of health (Green & Kreuter,
the health-care system (Lalonde, 1974; Tulchinsky 1999). The Ottawa Charter is agreed upon by most
& Varavikova, 2000). The development of health authors as the single most important document in the
promotion policies, programs, and initiatives in the history of health promotion (Wilcock & Whiteford,
later part of the 1970s and through the 1980s was 2003, p. 60). Three essential issues of concern to those
influenced by the identification of the reduction of involved in health were identified in the Ottawa Charter:
lifestyle risk factors as a means to improve health and caring, holism, and ecology. Figure 4-3 displays the
decrease health-care costs. However, concern was five directions identified by the Ottawa Charter to
expressed that the focus on lifestyle could lead reach the long-term goal of healthier communities. The
to blaming the victim and restriction of access to figure also includes roles or actions identified by
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Chapter 4 Public Health Principles, Approaches, and Initiatives 77

Build Healthy Create Supportive Strengthen Develop Reorient Health

Public Policy Environments Community Action Personal Skills Services
Type of Ecology Enable Enable Enable
economy Environmental Mediate Mediate Mediate
Cultural values management Advocate for: Advocate for: Advocate for:
National policies Technology Opportunity Energy Inclusion of
and priorities Commercial Friendliness Balance various
Justice factors Sharing Opportunity occupations
Education Stability Challenge toward social
Media Support Exercise development,
Fair systems Accessibility Rest economic
Gender issues Belonging Relaxation development,
Recreation Development Pleasure and individual
Access/space Flexibility Growth goals
Comfort/beauty Openness Purpose Accessibility of
Potential Meaning occupational
Equity of
and resources

Figure 4-3 Wilcock and Whitefords categorization of the Ottawa Charters five directions (WHO, 1986).
From Figure 4-2 from Occupation, health promotion, and the environment (p. 61) by A. Wilcock and G. Whiteford in Using environments to enable performance,
2003, Thorofare, NJ: SLACK. Reprinted with permission from SLACK Incorporated.

Wilcock and Whiteford (2003, p. 60) that would match Increase community capacity and empower the
the values and outcomes of occupation-based practice individual.
and research that promotes occupational justice. Occu- Secure an infrastructure for health promotion
pational justice is a critical perspective of social (WHO, 1997a, pp. 34).
structures that promotes social, political, and economic
changes to enable people to meet their occupational International Classification of Functioning,
potential and experience well-being (Spear & Crepeau, Disability, and Health (ICF)
2003, p. 1031). An occupationally just society pro- The international health community uses the ICF as a
motes occupational engagement for all members standard common language and framework to
through access to education, health, and recreational describe health status and factors that influence health
services that support quality of life of individuals, fam- and wellbeing (WHO, 2001). This document is one of
ilies, and communities through policy and public health the WHOs family of international classifications.
initiatives. The development of the Framework was influenced
by the ICF. Besides providing consistent health lan-
Jakarta Declaration on Leading Health guage across nations, the ICF also provides a struc-
Promotion into the 21st Century ture for advocacy for individuals with disabilities, the
This document identified the critical role of the environ- study of health systems, and the development
ment in health, while echoing the call of the Ottawa and evaluation of health and social policy. Content
Charter to address the underlying social conditions that Box 4-2 displays the services, systems, and policies
impact health, such as access to shelter, food, living defined within the classification that would be of
wages, and sustainable resources (Wilcock & Whiteford, interest in public health initiatives.
2003). Health promotion was described as being carried
out by and with people, not on or to people (WHO, Twenty Steps for Developing a Healthy
1997a, p. 4). Five priorities for the 21st century regard- Cities Project
ing health promotion were identified:
This is the third edition of a document that describes
Promote social responsibility for health. the ongoing work of the WHO Regional Office for
Increase investments for health development. Europe to improve the public health and determinants of
Consolidate and expand partnerships for health. health in the inhabitants of their cities. Eleven qualities of
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78 SECTION I Foundations and Key Concepts

Content Box 4-2 Implications for Occupational Therapy

International Classification of The international documents briefly described can be
Functioning, Disability, and used to inform practice and enhance the education of
occupational therapy and occupational therapy assis-
Health (ICF) tant students. These five documents are representa-
tive of the many available international documents
SubcategoriesServices, Systems, and Policies and have been used by occupational therapists
Services, systems, and policies for the production around the world to support work in public health,
of consumer goods health promotion, and occupational justice. Several
Architecture and construction services, systems, of these and other similar international documents
and policies have been cited in descriptions of community-based
Open-space planning services, systems, and policies rehabilitation and other occupational therapy public
Housing services, systems, and policies health initiatives directed toward marginalized people
Utilities services, systems, and policies throughout the world (Kronenberg, Sim-Algado, &
Communication services, systems, and policies Pollard, 2005). In addition, the philosophy and human
Transportation services, systems, and policies values represented in these documents resonate in
Civil protection services, systems, and policies the position paper on community-based rehabilitation
Legal services, systems, and policies developed by the World Federation of Occupational
Associations and organizational services, systems, Therapists (WFOT) in June 2004.
and policies Although the WFOT and occupational therapists
Media services, systems, and policies from a variety of countries have been actively
Economic services, systems, and policies engaged in contributing to the public health of popu-
Social Security services, systems, and policies lations and countries in need around the world
General social support services, systems, and (Kronenberg et al., 2005), less has been done within
policies the United States to promote public health and occu-
Health services, systems, and policies pational justice. While innovative occupational therapy
Education and training services, systems, and models exist, they do not reach the needs of many
policies marginalized people within U.S. borders. Awareness
Labor and employment services, systems, and of these documents is a first step in the education of
policies students. The second step is educating students
Political services, systems, and policies about health disparities and marginalized populations
Services, systems, and policies, other specified within the United States and around the world. With
Services, systems, and policies, unspecified this knowledge, students will be better prepared to
advocate for public health and occupational therapys
Data from an overview of ICF from International classification of contribution to public health, both within their country
functioning, disability, and health (p. 44) by World Health Organiza- and abroad.
tion (WHO), 2001, Geneva, Switzerland. Copyright 2001 by WHO.

a healthy city are identified in this document and appear Health Care (IOM, 2003), was written at the request of
in Content Box 4-3. Although the document and pro- the U.S. Congress. These documents include
cesses were designed for European cities, the document Healthy People 2010: Understanding and Improv-
includes useful information for the design of any interdis- ing Health (USDHHS, 2000a);
ciplinary project to impact the health of a city or commu- Healthy People in Healthy Communities: A Com-
nity. Phase IV of the WHO Healthy Cities Network in munity Planning Guide Using Healthy People
Europe ran from 2003 through 2007. Focus areas for this 2010 (USDHHS, 2001a);
phase included healthy urban planning, health impact Unequal Treatment: Confronting Racial and Eth-
assessment, and healthy aging. All six WHO regions have nic Disparities in Health Care (IOM, 2003);
established Healthy City networks (WHO, 2005b). Healthy Campuses 2010: Making It Happen
(American College Health Association, 2002)
Youth Violence: A Report of the Surgeon General
U.S. Governmental Documents (USDHHS, 2001b); and
on Health Promotion Mental Health: A Report of the Surgeon General
(USDHHS, 1999).
A variety of U.S. governmental documents are also avail-
able to provide assistance with needs assessment and After each document has been described, one or
health promotion program development. Six of these more implications for the profession of occupational
documents, five of which are official U.S. documents, therapy will be shared, along with thoughts regarding
are described below. The other document, Unequal future directions for the specific population, health
Treatment: Confronting Racial and Ethnic Disparities in condition, or threat addressed by the report.
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Chapter 4 Public Health Principles, Approaches, and Initiatives 79

Content Box 4-3 Healthy People 2010: Understanding

and Improving Health
Qualities of a Healthy City This document continues the tradition established with
A city should strive to provide previous federal government publications, which out-
a clean, safe physical environment of high quality line proactive health goals and objectives for the
(including housing quality); United States and its citizens. These national health
an ecosystem that is stable now and sustainable goals and objectives are developed through a collabora-
in the long-term; tive process between governmental, professional, and
a strong, mutually supportive and nonexploitive
nonprofit organizations, and the public. The AOTA
a high degree of participation and control by the was a member of the Healthy People Consortium, an
public over the decisions affecting their lives, alliance of more than 350 national organizations and
health, and wellbeing; 250 State public health, mental health, substance
the meeting of basic needs (for food, water, shelter, abuse, and environmental agencies involved in the
income, safety, and work) for all the citys people;
access to a wide variety of experiences and
development of Healthy People 2010: Understanding
resources, with the chance for a wide variety of and Improving Health (USDHHS, 2000a, p. 2).
contact, interactions, and communication; Healthy People 2010: Understanding and Improv-
a diverse, vital, and innovative city economy; ing Health, frequently referred to as simply Healthy
the encouragement of connectedness with the People 2010, is comprised of a series of goals and
past, with cultural and biological heritage of city
dwellers, and with other groups and individuals;
objectives. Two overarching goals exist in Healthy
a form that is compatible with and enhances the People 2010. The first is to increase quality and years
preceding characteristics; of life, and the second is to eliminate health dispari-
an optimum level of appropriate public health and ties (USDHHS, 2000a, p. 2). In addition to these
sick care services accessible to all; and overarching goals, the report includes 467 objectives
high health status (high levels of positive health
and low levels of disease).
divided into 28 focus areas. Table 4-2 lists a sampling
of objectives with potential interest to occupational
Data from Figure 1 in Twenty steps for developing a healthy cities therapy practitioners. This list includes examples of
project (p. 9) by the World Health Organization (WHO), Regional objectives that correlate to all three levels of preven-
Office for Europe, 1997, Copenhagen, Denmark. Copyright 1997 by
WHO, Regional Office for Europe. tion. Achievement of these objectives will not occur
through occupational therapy personnel working in
isolation; progress will be made only if occupational
therapy practitioners join or initiate interdisciplinary
efforts to target one or more of these objectives.

Table 42 Examples of Healthy People 2010 Objectives Related to Health Promotion

Domain of Concern Objective Number Objective

Access to Quality 1-7 (Developmental) Increase the proportion of schools of medi-
Health Services cine, schools of nursing, and other health professional train-
ing schools whose basic curriculum for health-care providers
includes the core competencies in health promotion and dis-
ease prevention.
1-8 In the health professions, the allied and associated health
profession fields, and the nursing field, increase the propor-
tion of all degrees awarded to members of underrepresented
racial and ethnic groups.
Arthritis, Osteoporosis, 2-1 (Developmental) Increase the mean number of days
and Chronic Back Conditions without severe pain among adults who have chronic joint
2-7 (Developmental) Increase the proportion of adults who have
seen a health-care provider for their chronic joint symptoms.
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80 SECTION I Foundations and Key Concepts

Table 42 Examples of Healthy People 2010 Objectives Related to Health Promotioncontd

Domain of Concern Objective Number Objective

2-8 (Developmental) Increase the proportion of persons with arthri-
tis who have had effective, evidence-based arthritis education
as an integral part of the management of their condition.
Cancer Deaths and 3-9 Increase the proportion of persons who use at least one
Disabilities of the following protective measures that may reduce
the risk of skin cancer: avoid sun between 10 a.m. and
4 p.m., wear sun-protective clothing when exposed to sun-
light, use sunscreen with a sun-protective factor (SPF) of
15 or higher, and avoid artificial sources of ultraviolet light.
Disability and Secondary 6-3 Reduce the proportion of adults with disabilities who report
Conditions feelings such as sadness, unhappiness, or depression that
prevent them from being active.
6-6 Increase the proportion of adults with disabilities reporting
satisfaction with life.
6-7 Reduce the number of people with disabilities in congregate
care facilities, consistent with permanency planning programs.
Educational and 7-7 (Developmental) Increase the proportion of health-care
Community-Based organizations that provide patient and family education.
7-8 (Developmental) Increase the proportion of patients who
report that they are satisfied with the patient education they
receive from their health-care organization.
7-9 (Developmental) Increase the proportion of hospitals and
managed care organizations that provide community
disease prevention and health promotion activities that
address the priority health needs identified by their
7-12 Increase the proportion of older adults who have participated
during the preceding year in at least one organized health
promotion activity.
Heart Disease and 12-11 Increase the proportion of adults with high blood pressure
Stroke who are taking action (for example, losing weight, increasing
physical activity, or reducing sodium intake) to help control
their blood pressure.
Injury and Violence 15-12 Increase the number of states and the District of
Prevention Columbia that collect data on external causes of injury
through hospital discharge data systems.
15-33 Reduce maltreatment and maltreatment fatalities of children.
15-39 Reduce weapon-carrying by adolescents on school property.
Mental Health and 18-5 (Developmental) Reduce the relapse rates for persons with
Mental Disorders eating disorders, including anorexia nervosa and bulimia
18-8 (Developmental) Increase the proportion of juvenile justice
facilities that screen new admissions for mental health
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Chapter 4 Public Health Principles, Approaches, and Initiatives 81

Table 42 Examples of Healthy People 2010 Objectives Related to Health Promotioncontd

Domain of Concern Objective Number Objective

18-9 Increase the proportion of adults with mental disorders who
receive treatment.
Physical Activity and 22-1 Reduce the proportion of adults who engage in no leisure-
Fitness time physical activity.
22-7 Increase the proportion of adolescents who engage in vigor-
ous physical activity that promotes cardiorespiratory fitness 3
or more days per week for 20 or more minutes per occasion.
22-11 Increase the proportion of adolescents who view television 2
or fewer hours on a school day.
22-12 (Developmental) Increase the proportion of the nations public
and private schools that provide access to their physical activ-
ity spaces and facilities for all persons outside of normal
school hours (that is, before and after the school day, on
weekends, and during summer and other vacations).
22-13 Increase the proportion of worksites offering employer-
sponsored physical activity and fitness programs.
Substance Abuse 26-19 (Developmental) Increase the proportion of inmates receiving
substance abuse treatment in correctional institutions.

Data from Healthy People 2010: Understanding and improving health, by U.S. Department of Health and Human Services, 2000, Washington, DC:
Government Printing Office.

Focus area 6 of Healthy People 2010 is devoted to ground information regarding health determinants, data
the promotion of wellbeing and the prevention of sec- on the nations current health status, and top health
ondary conditions for people with disabilities. This indicators. Health determinants and the relationships
focus area had not been included in previous versions with health status are identified in Figure 4-4. Data
of Healthy People and demonstrates a growing under- such as the leading causes of death by age group are
standing of the health promotion needs of individuals included in this report (Table 4-3 on page 83). Ten lead-
and populations with disabilities. People with disabil- ing health priority indicators reflecting major U.S. pub-
ities are at increased risk for secondary conditions, lic health concerns will be used to track the progress of
which include more than just physical health issues. Healthy People 2010.
Emotional distress prompted by barriers and lack of
These 10 Leading Health Indicators are intended to
access to opportunities for social participation can
help everyone more easily understand the importance
lead to a variety of mental health issues, including
of health promotion and disease prevention. Motivat-
sleep abnormalities and depression. Table 4-2 includes 3
ing individuals to act on just one of the indicators
of the 13 objectives related to individuals with
can have a profound effect on increasing the quality
disabilities associated with this focus area. The major-
and years of healthy life and on eliminating health
ity of these objectives focus on helping people with
disparitiesfor the individual, as well as the commu-
disabilities be involved in all aspects of life through
nity overall. (USDHHS, 2001a, p. 4)
improving access to education, employment, equip-
ment, and health promotion activities. Also, three of Table 4-4 on page 84 lists the 10 leading health indicators
the objectives focus directly on the mental health together with corresponding public health challenges.
needs of this population. There are additional resources that provide
In addition to outlining goals and objectives for the updated data and information concerning the imple-
nations health, Healthy People 2010 provides back- mentation of Healthy People 2010, which include a
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82 SECTION I Foundations and Key Concepts

Determinants of Health Implications for Occupational Therapy

Policies and Interventions Healthy People 2010 is an important resource for
occupational therapy assistants and occupational
therapists in research, practice, and education. All
graduating occupational therapy and occupational
Behavior therapy assistant students should be conversant
with this report. It can be accessed online free of
charge by clicking on the publications link on the
Physical Social Healthy People 2010 homepage, which is accessible
Environment Environment
at http://www.healthypeople.gov/About/. Knowledge
of this document and its objectives is essential for
Biology interdisciplinary work in health promotion and public
health as well as occupational therapyspecific inter-
ventions that address the level of context in the
Framework (AOTA, 2008). This knowledge is also
Access to Quality Health Care very useful when writing grants to secure funding
for related work that seeks to enhance community
wellbeing and social participation by community
Figure 4-4 Determinants of health. members.
From Figure 7 in Healthy People 2010: Understanding and improving health
(p. 18), by U.S. Department of Health and Human Services, 2000, Washington,
DC: Government Printing Office.

Healthy People in Healthy Communities:

A Community Planning Guide Using
midcourse review, tracking reports, and progress Healthy People 2010
reviews. It is customary for the USDHHS to release In addition to Healthy People 2010, many parallel
a midcourse review of progress toward the current efforts exist, two of which are described in this chap-
decades goals and objectives. The midcourse ter. The first of these efforts to be described is Healthy
review for Healthy People 2010 was released in People in Healthy Communities: A Community Plan-
December 2006 (USDHHS, 2006) and can be found ning Guide Using Healthy People 2010, a guide to
by clicking on the publications link on the Healthy help citizens form and operate community coalitions
People 2010 homepage, which is accessible at (USDHHS, 2001a). A healthy community is
http://www.healthypeople.gov/About/. A second described as a community that
resource is Tracking Healthy People 2010, a statisti-
provides access to both preventive and clinical
cal companion to Healthy People 2010, which also
health services to all residents;
can be found by clicking on the publications link on
has a safe and healthy atmosphere; and
the Healthy People 2010 homepage. This document
has an infrastructure (e.g., roads, schools,
is a comprehensive, authoritative guidebook on the sta- playgrounds, and other services) to meet
tistics used for Healthy Peoplein effect the analytic the needs of community members (USDHHS,
framework for the program. Never before has the broad 2001a).
Healthy People community had this type of resource.
This guide describes the Healthy People 2010 initia-
This guidebook will assist in ensuring greater accuracy
tive and a step-by-step process that can be used to
and comparability in the data produced for, and used
assess the community and to promote change. The
by, Healthy People 2010 programs at the local, State,
stepsmobilize, assess, plan, implement, and track
and national levels. (USDHHS, 2000b, Foreword 2)
spell out MAP-IT, which is the acronym used to iden-
A third type of resource is progress reviews. tify the process. This process is briefly highlighted in
The first of two planned Healthy People 2010 Chapter 10 of this book.
progress reviews began in 2002, with the goal of While the document Healthy People in Healthy
reviewing one of the 28 focus areas, roughly in Communities is an excellent resource, it is not suffi-
alphabetical order, on a monthly basis (USDHHS, cient to combat the social injustices and disparities in
2004). These progress reviews can be accessed resources that exist in communities across the United
through the Healthy People 2010 homepage, via the States. Funding and support for communities with the
implementation link. human capital to locate and use this resource are
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Chapter 4 Public Health Principles, Approaches, and Initiatives 83

Implications for Occupational Therapy

Table 43 Leading Causes of Death by
Age Group A healthy community supports optimal occupational
performance as presented in the AOTAs Frame-
Under 1 Year Number of Deaths work. However, the Framework does not discuss or
define community but instead describes compo-
Birth defects 6178 nents of a community through its explanation of
Disorders related to 3925 contexts. Healthy People in Healthy Communities
premature birth helps occupational therapists and occupational ther-
apy assistants begin to think in terms of a commu-
Sudden infant death 2991 nity as a potential client.
14 Years Unequal Treatment: Confronting Racial
Unintentional injuries 2005 and Ethnic Disparities in Health Care
Birth defects 589 The Institute of Medicine (IOM) 2003 report Unequal
Treatment: Confronting Racial and Ethnic Disparities
Cancer 438 in Health Care details disparities that exist in
514 Years access to health care and outlines disparities that cur-
Unintentional injuries 3371 rently exist in the U.S. health-care delivery system.
Health-care disparities are racial or ethnic differ-
Cancer 1030 ences in the quality of healthcare that are not due to
Homicide 457 access-related factors or clinical needs, preferences,
1524 Years
and appropriateness of intervention (IOM, 2003, pp.
34). The findings of this report appear in Content Box
Unintentional injuries 13,367 4-4. Evidence of health-care disparities continued with
Homicide 6146 the publication of the congressionally mandated report
Suicide 4186 National Healthcare Disparities Report (Agency for
Healthcare Research and Quality, 2005). A summary of
2444 Years

Unintentional injuries 27,129

Implications for Occupational Therapy
Cancer 21,706
Occupational therapists and occupational therapy
Heart disease 16,513 assistants take an active role in eliminating health-
4564 Years care disparities within the United States. Potential
actions include the following:
Cancer 131,743
Participate in the AOTA and state associations and
Heart disease 101,235 promote awareness of the IOM report.
Unintentional injuries 17,521
Require review of this and other similar reports
within occupational therapy educational programs
65 Years and Older and fieldwork.
Monitor service delivery patterns to ensure dispar-
Heart disease 606,913 ities do not exist.
Cancer 382,913 Advocate and be politically active to ensure neces-
sary polices, laws, and regulations are enacted
Stroke 140,366 and implemented.
Engage in evidence-based, culturally competent
Adapted from Figure 9 in Healthy People 2010: Understanding and practice.
improving health (p. 23), by U.S. Department of Health and Human Embrace and conduct research on ethical issues
Services, 2000, Washington, DC: Government Printing Office. in service delivery.
Active involvement to eliminate health-care dispar-
ities within the United States is consistent with the
Occupational Therapy Code of Ethics (AOTA, 2005),
required. Even more critical are the efforts that must the Core Values and Attitudes of Occupational Ther-
be made to ensure all communities are aware of this apy Practice (AOTA, 1993), the AOTAs statement on
document and have access to the supports to realize Health Disparities (Braveman, 2006), and the AOTAs
statement Occupational Therapys Commitment to
the goal of healthy communities across the entire Nondiscrimination and Inclusion (AOTA, 2004).
U.S. landscape.
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84 SECTION I Foundations and Key Concepts

Table 44 Leading Health Indicators and Corresponding Public Health Challenge

Subject/Topic Public Health Challenge

Physical activity Promote regular physical activity
Overweight and obesity Promote healthier weight and good nutrition
Tobacco use Prevent and reduce tobacco use
Substance abuse Prevent and reduce substance abuse
Responsible sexual behavior Promote responsible sexual behavior
Mental health Promote mental health and wellbeing
Injury and violence Promote safety and reduce violence
Environmental quality Promote healthy environments
Immunization Prevent infectious disease through immunization
Access to health care Increase access to quality health care

From Healthy People in Healthy Communities 2010: Understanding and improving health (p. 24), by U.S. Department of Health and Human
Services, 2000, Washington, DC: Government Printing Office.

the IOM (2003) recommendations for reducing health

Content Box 4-4
disparities can be found in Appendix B.
Summary of Findings of Institute Healthy Campuses 2010: Making It Happen
of Medicine (IOM) Report
This is the second document related to Healthy People
Finding 1-1: Racial and ethnic disparities in 2010 to be discussed. This document provides colleges
health care exist and, because they are associ-
ated with worse outcomes in mean cases, are and universities with the structure to assess the health
unacceptable. status of their campuses and make decisions regarding
Finding 2-1: Racial and ethnic disparities in health priorities and interventions. In addition to this report,
care occur in the context of broader historic and data collected and reported by ACHA through the
contemporary social and economic inequality, and National College Health Assessment (NCHA) can
evidence of persistent racial and ethnic discrimina-
tion in many sectors of American life. assist with decision-making. The NCHA collects data
Finding 3-1: Many sourcesincluding health sys- nationally on college and university students health
tems, health-care providers, patients, and utilization behaviors and perceptions on
managersmay contribute to racial and ethnic
disparities in health care. alcohol, tobacco, and other drug use;
Finding 4-1: Bias, stereotyping, prejudice, and sexual health;
clinical uncertainty on the part of health-care weight, nutrition, and exercise;
providers may contribute to racial and ethnic mental health; and
disparities in health care. While indirect evidence
from several lines of research supports this injury prevention, personal safety, and violence
statement, a greater understanding of the preva- (ACHA, 2004, NCHA 2).
lence and influence of these processes is
needed and should be sought through research. Currently in the United States there are 128 accred-
Finding 4-2: A small number of studies suggest ited occupational therapy assistant education programs
that racial and ethnic minority patients are more (AOTA, 2009). The campuses on which these programs
likely than white patients to refuse treatment. reside may seek assistance from the Bridges to Healthy
These studies find that differences in refusal Communities 2005 program. This program is managed
rates are generally small and that minority
patient refusal does not fully explain health- through the American Association of Community Col-
care disparities. leges (AACC) in cooperation with the Centers for
Disease Control and Preventions (CDC) Division of
From box in Unequal treatment: Confronting racial and ethnic disparities Adolescent and School Health. Resources are available
in healthcare (p. 19), by Institute of Medicine, 2003, Washington, DC:
National Academies Press. Reprinted with permission from the National to assist with program replication and development, with
Academies Press. Copyright 2003 by National Academy of Sciences. an emphasis on the prevention of HIV infection.
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Chapter 4 Public Health Principles, Approaches, and Initiatives 85

The Bridges project is helping community colleges The NCIP established research priorities for pre-
improve student and community health through mod- venting youth violence. The top 7 of 15 priorities to be
els of integrated activities that bring together campus emphasized over the next 3 to 5 years are listed below:
and community. They involve individuals, families,
schools, and communities. Service learning is the pri-
Evaluate dissemination strategies for the most
mary strategy and is supplemented by a variety of spe-
effective youth violence prevention programs.
cific strategies left to the creativity and imagination of
Evaluate the effectiveness of community-wide
the colleges. (AACC, 2004, About the project, 1)
parenting programs for youth violence prevention.
Evaluate the effectiveness of youth violence
prevention strategies.
Youth Violence: A Report of the Surgeon Identify and evaluate strategies to decrease inap-
General propriate access to and use of firearms among
The tragic events at Columbine High School in 1999 youths.
brought the public health problem of youth violence Identify modifiable sociocultural and community
to the forefront and were the catalyst for Youth Violence: factors that influence youth violence.
A Report of the Surgeon General (USDHHS, 2001b). Identify modifiable factors that protect youths from
At the beginning of her report, the secretary of becoming victims or perpetrators of violence.
USDHHS, Dr. Donna E. Shalala, stated that the first, Clarify the relationships between youth violence
most enduring responsibility of a society is to ensure the and other forms of violence and determine impli-
health and wellbeing of its children (p. i). Shalala then cations for prevention. (CDC/NCIP, 2004b, The
described how President Clinton directed the Surgeon Injury Centers Research Priorities, 123)
General to prepare a report summarizing the current
research on the scope, causes, and possible prevention of The information gathered and disseminated from
youth violence. The Office of the Surgeon General super- evidence-based research in these areas will inform
vised the preparation of the Youth Violence report, which future legislation, policies, and program development
was a collaborative effort between the USDHHS; the CDC; and refinement.
the National Institutes of Health, National Institute of Men-
tal Health (NIH/NIMH); and the Substance Abuse and
Mental Health Services Administration (SAMHSA).
Then Surgeon General, Dr. David Satcher, summa- Implications for Occupational Therapy
rized the overall report findings in the preface. The The findings of the Youth Violence report (USDHHS,
following were among his comments: 2001b) support the need for evidence-based violence
prevention practice. Best Practices of Youth Violence
No community is immune. Prevention: A Sourcebook for Community Action
Intervention strategies exist today that can be tai- (Thornton, Craft, Dahlberg, Lynch, & Baer, 2002) is
lored to the needs of youths at every stage of devel- another source for successful programs and ideas
opment, from young childhood to late adolescence. upon which to build occupational therapys contribu-
Strategies that are effective for one age may be tions to the prevention of youth violence in the commu-
nity. By critically reviewing the literature for efficacious
ineffective for older or younger children. Certain programs, the occupational therapist can more quickly
hastily adopted and implemented strategies may be prepared to contribute to interventions that will
be ineffectiveand even deleteriousfor all more likely achieve desired outcomes.
children and youth (USDHHS, 2001b, p. v). The Families and Schools Together (FAST) program
is another resource for occupational therapy practi-
The CDCs National Center for Injury Prevention tioners. The original FAST program was developed by
and Control (NCIP) cooperates with other agencies a social worker in 1988 (AOTA, 2003). The AOTA
to maximize collaboration and the dissemination of conducted a FAST violence prevention research
project from September 2000 through May 2001,
research, and it conducts which was funded by the Center for Mental Health
research on violence-related injuries across contexts (e.g., Services (CMHS), a division of the Substance
Abuse and Mental Health Services Administration
school, family, community), roles (i.e., victim or perpe- (SAMHSA). An occupation-based, multifamily, 10-
trator), and proximal causes (e.g., intoxication, bullying, week program was developed and implemented at
robbery), combined with its emphasis on prevention two different schools, one in a Midwest city and one
strategies, complements and extends the violence-preven- in a Northeast suburb. Positive program results were
tion activities of other federal agencies and community- consistent with previous FAST initiatives, thus it was
determined that occupational therapists would be
based organizations. (CDC/NCIP, 2004a, The Injury appropriate FAST team leaders (AOTA, 2003).
Centers Niche in Preventing Youth Violence, 4)
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86 SECTION I Foundations and Key Concepts

Mental Health: A Report of the Surgeon future action were identified, including the following:
Continue to build the science base.
Mental health is viewed as a dynamic phenomenon Implement strategies to overcome stigma.
that reflects an individuals genetic predispositions, Ensure an appropriate array of mental health
life experiences, and social environment. Although services and an adequate supply of practitioners.
the physical health of the U.S. population progres- Provide culturally competent care.
sively improves, mental health is often overlooked, Reduce barriers to evidence-based interventions.
and mental illnesses remain shrouded in stigma and (USDHHS, 1999)
misunderstanding. The report of the U.S. Surgeon
General regarding mental health emphasizes the inter- Although significant efficacy data exists to support a
dependent nature of physical and mental health and range of treatments for mental disorders, there is a
wellbeing, and focuses attention on the mental health paucity of research on preventive interventions. More
needs of persons across the life span (USDHHS, attention focused on strategies for promoting mental
1999). Approximately 20% of individuals within the health and facilitating resiliency is essential. The con-
United States are affected by mental disorders in any ditions necessary for developing and maintaining men-
given year; depression is a leading cause of disability tal health and preventing mental illness are priorities
in the United States, and suicide is one of the leading for future research.
preventable causes of death worldwide. Yet, the avail-
ability and accessibility of mental health services lack
parity with other areas of health care. Due to recent Implications for Occupational Therapy
advances in neurophysiology, mental illnesses are
The number of occupational therapists and occupa-
more effectively treated than at any other point in his- tional therapy assistants in mental health practice
tory. However, there is a serious lack of research on has significantly declined over the past 20 years. In
efficacious strategies to prevent mental disorders and 2004, only 2% of occupational therapy practitioners
promote mental health. worked in mental health settings, down from 8.5% in
Several themes are evident in the Surgeon Generals 1986 (Ebb & Haiman, 1990; Gandy, 2004). It is dis-
concerting that occupational therapy is losing its
report on mental health, including presence in the mental health arena, where the pro-
fession first emerged and demonstrated its worth.
mental health and mental illness should be According to WHO, depression is the leading
approached from a public health perspective; cause of disability in terms of years lived with disabil-
mental disorders are significantly disabling; ity (YLD). It is the fourth leading cause of disability as
mental health and mental illness are points on a measured by DALYs (disability adjusted life years).
DALYs refers to the sum of years of potential life lost
continuum, not polar opposites; due to premature mortality and years of productive
the mind and body are inseparable; and life lost due to disability. It is expected that by the
stigma is a serious barrier that reduces access year 2020, depression will be the second leading
to treatment, limits opportunities, interferes cause of DALYs among all age groups and for both
with full participation in society, and sexes (WHO, 2006c).
Since mental disorders (especially depression) are
may result in overt discrimination disabling, it is essential for occupational therapists to
(USDHHS, 1999). actively reinvigorate this area of practice. As lifestyle
redesign (University of Southern California, Depart-
The report was based on the best available scien- ment of Occupational Therapy & Occupational Science,
tific evidence at the time and addresses the unique n.d.) specialists, occupational therapists can have a
role in the prevention of mental disorders and the pro-
mental health needs of children, adolescents, adults, motion of mental health. Mental health promotion can
and the elderly. Each stage of life is associated with be integrated into practice regardless of the setting
specific vulnerabilities for mental illness and distinct and population served. Genetics, life experiences,
capacities for mental health. In addition to chapters and social environment affect mental health. Occupa-
describing mental health and mental illness at each tional therapists and occupational therapy assistants
can provide positive mental health promotion life
stage of the life cycle, other chapters in the report dis- experiences and can facilitate the development of
cuss issues related to the organization and financing social networks and thereby promote mental health.
of mental health services and issues of privacy and The Surgeon Generals report clearly indicates that
confidentiality. mental health is a health problem across the life span.
Based on the findings of the Surgeon Generals As such, it must be addressed for all people, not just
for persons with mental illness.
report on mental health, numerous recommendations for
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Chapter 4 Public Health Principles, Approaches, and Initiatives 87

U.S. Government and The Olmstead v. L.C. decision, issued by the U.S.
Supreme Court in July 1999, declared that unnecessary
Professional Association segregation of persons with disabilities in institutions vio-
Public Health Initiatives lates the Americans with Disabilities Act (ADA) of 1990
and constitutes discrimination. The decision applies to all
This last section will focus on initiatives sponsored by persons with physical or mental disabilities, regardless of
the U.S. government and U.S.-based professional age. It challenges local, state, and federal governments to
organizations to impact public health in the United provide accessible, cost-effective, community-based ser-
States and abroad. Four examples will be shared, vices for people with disabilities. The NFI mandates full
including former President George W. Bushs New implementation of the Olmstead v. L.C. decision.
Freedom Initiative, the Presidents New Freedom In 2004, a progress report was released describing
Commission on Mental Health (Bush, 2002), the the NFIs accomplishments. Content Box 4-5 highlights
AOTAs official document on health promotion, and some of the achievements related to each goal.
the American Occupational Therapy Foundations The U.S. Department of Justice (USDOJ) houses
Occupation in Societal Crises Task Force report. the homepage of the ADA, the forerunner of the NFI.
New Freedom Initiative: Fulfilling Americas This homepage includes links to an area that displays
Promise to Americans with Disabilities case studies of people whose lives and occupations
have been positively impacted by the ADA
Approximately 54 million people in the United States (USDOJ, 2000). One of the cases pertains to a boy
live with a disability. This represents nearly 20% of the whose parents, with the help of the USDOJ, ensured
population. The New Freedom Initiative (NFI), his continued access to an after-school program oper-
announced by former President George W. Bush on ated by a national day-care chain.
February 1, 2001, is a comprehensive national frame-
work for eliminating barriers that prevent people with
disabilities from fully participating in community life. Implications for Occupational Therapy
Six federal agencies are directly involved, including the
Departments of Health and Human Services, Education, The ADA and now the NFI provide an outstanding
Labor, Housing and Urban Development, and Justice, opportunity for occupational therapists and occupa-
as well as the Social Security Administration. Several tional therapy assistants to become involved in a
national effort to eliminate barriers to full inclusion and
other departments and agencies are involved indirectly. social participation for children, adults, and elderly per-
The NFI has six goals, which include sons with disabilities. Occupational therapy can posi-
tively impact all six goals of the NFI. Occupational ther-
increasing access to assistive and universally apy professionals have knowledge and skills in
designed technologies; assistive technology, school-system interventions,
expanding educational opportunities; home adaptations, work-skill development, transporta-
promoting home ownership; tion adaptations, and facilitating community integra-
integrating Americans with disabilities into the tion and social participation. The U.S. Supreme Courts
Olmstead v. L.C. decision mandates community-
workforce; based services for people with disabilities. Occupa-
expanding transportation options; and tional therapists are uniquely positioned to respond to
promoting full access to community life (USDHHS, the NFI and the Olmstead decision by developing and
2003b, 3). providing accessible, cost-effective health promotion
and occupation-based interventions in the community.
On June 18, 2001, as part of the NFI, former Presi-
dent George W. Bush issued Executive Order 13217:
Community-Based Alternatives for Individuals with Presidents New Freedom Commission
Disabilities: on Mental Health
The Order called upon the federal government to A key component of the New Freedom Initiative was
assist states and localities to swiftly implement the the establishment of the Presidents New Freedom
decision of the United States Supreme Court in Commission on Mental Health in 2002. The commis-
Olmstead v. L.C. stating: The United States is com- sions purpose was to conduct a comprehensive evalu-
mitted to community-based alternatives for individu- ation of the mental health service delivery system
als with disabilities and recognizes that such services and provide recommendations on how the system could
advance the best interests of the United States. be improved. For nearly a year, 22 commissioners met
(USDHHS, 2003c, 1) monthly to hear testimony, analyze the mental health
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88 SECTION I Foundations and Key Concepts

Content Box 4-5 The commission was mandated to identify unmet

needs, barriers to community-based services, and
Selected Achievements of the New effective treatment approaches and to formulate poli-
Freedom Initiative cies to enhance community integration of persons with
mental disorders. The ultimate goal is to create a
Goal: Increasing Access to Assistive and system of services that enable persons with serious
Universally Designed Technologies mental illnesses to live, work, learn, and participate
Funded alternative financing programsfor exam- fully in their communities.
ple, low-interest, long-term loans to enable persons In 2003, the final report of the commission was
with disabilities to acquire needed technologies
Promoted full implementation of Section 508 of released. A complete transformation of the mental
the Rehabilitation Act to ensure that electronic and health service delivery system was advocated, and
information technologies used by the government two principles for this transformation were outlined.
are fully accessible to persons with disabilities First, the services must be client- and family-centered,
Developed a Web portal, DisabilityInfo.gov, that not oriented to the needs of bureaucracies. Second,
provides information about the variety of programs
offered by the federal government that impact peo- intervention should focus on building resilience and
ple with disabilities facilitating recovery, not simply on reducing symp-
Goal: Expanding Educational Opportunities toms. In addition, interventions should be based on the
for Youth With Disabilities best available evidence, and the system must be conve-
Established the Presidents Commission on Excel- nient, accessible, and built upon client needs. Accord-
lence in Special Education ing to the report, in a transformed mental health ser-
Increased funding for the Individuals with Disabilities vice,
Education Act (IDEA)
Americans understand that mental health is essen-
Goal: Integrating Americans With Disabilities
Into the Workforce tial to overall health;
Provided funding to purchase technology to enable mental health care is consumer and family driven;
telecommuting disparities in mental health services are eliminated;
Implemented the Ticket to Work program early mental health screening, assessment, and
Promoted strict enforcement of the Americans referral to services are common practice;
with Disabilities Act (ADA) of 1990 excellent mental health care is delivered and
Developed best practice models for hiring and
retaining qualified individuals with disabilities research is accelerated; and
technology is used to access mental health care
Goal: Promoting Full Access to Community Life
and information (Presidents New Freedom
Improved access to voting for persons with
disabilities Commission on Mental Health, 2003, p. 8).
Provided funding for projects to reduce transporta- The characteristics are written as goal statements in
tion barriers
Trained over 1500 architects and builders in the the report and serve as the framework for the commis-
design and construction of fully accessible housing sions 19 recommendations (see Content Box 4-6).
Funded projects to enable older individuals and
individuals with disabilities to remain in their homes
Provided employment transportation services for Implications for Occupational Therapy
individuals with disabilities
Funded demonstration projects for the recruitment, Two outcomes of the commissions deliberations are of
training, and retention of direct service workers special interest to occupational therapists and occupa-
Established the New Freedom Commission on tional therapy assistants. One is the provision of
Mental Health community-based services for persons with mental dis-
From The Presidents New Freedom Initiative for People with Disabilities: orders. Many mental health services are provided in
The 2004 progress report, executive summary (pp. 36), by the White community settings, but few of these include occupa-
House Domestic Policy Council Washington, DC: The White House. tional therapy. Occupational therapists need to promote
their unique focus, abilities, and skills to these programs
and advocate employment of occupational therapy pro-
fessionals for the benefit of mental health clients. In
system, visit innovative program models, and review addition, it is not only reasonable, but also imperative to
research evidence (Presidents New Freedom Commis- create new occupation-based programs for mental
sion on Mental Health, 2003). The U.S. Department of health clients living in the community. Occupational
therapists are particularly qualified to address the two
Health and Human Services Surgeon Generals 1999 broad principles of the commissions reportclient- and
report on mental health served as the scientific founda- family-centered care and building client resilience.
tion for the commissions deliberations.
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Chapter 4 Public Health Principles, Approaches, and Initiatives 89

Content Box 4-6

Goals and Recommendations in a Transformed Mental Health System

Goal 1: Americans Understand That Mental 4.3 Screen for co-occurring mental and substance
Health Is Essential to Overall Health use disorders and link with integrated treatment
Recommendations strategies.
4.4 Screen for mental disorders in primary health
1.1 Advance and implement a national campaign to care, across the life span, and connect to
reduce the stigma of seeking care and a national treatment and supports.
strategy for suicide prevention.
1.2 Address mental health with the same urgency Goal 5: Excellent Mental Health Care Is
as physical health. Delivered and Research Is Accelerated
Goal 2: Mental Health Care Is Consumer and Recommendations
Family Driven
5.1 Accelerate research to promote recovery and
Recommendations resilience, and ultimately to cure and prevent
2.1 Develop an individualized plan of care for every mental illnesses.
adult with a serious mental illness and child 5.2 Advance evidence-based practices using dis-
with a serious emotional disturbance. semination and demonstration projects and
2.2 Involve consumers and families fully in orienting create a public-private partnership to guide
the mental health system toward recovery. their implementation.
2.3 Align relevant federal programs to improve access 5.3 Improve and expand the workforce providing
and accountability for mental health services. evidence-based mental health services and
2.4 Create a comprehensive state mental health plan. supports.
2.5 Protect and enhance the rights of people with 5.4 Develop the knowledge base in four under-
mental illnesses. studied areas: mental health disparities,
long-term effects of medications, trauma, and
Goal 3: Disparities in Mental Health Services acute care.
Are Eliminated
Recommendations Goal 6: Technology Is Used to Access Mental
3.1 Improve access to quality care that is culturally Health Care and Information
competent. Recommendations
3.2 Improve access to quality care in rural and 6.1 Use health technology and telehealth
geographically remote areas. to improve access and coordination of
Goal 4: Early Mental Health Screening, Assessment, mental health care, especially for Americans
and Referral to Services Are Common Practice in remote areas or in underserved
Recommendations populations.
6.2 Develop and implement integrated electronic
4.1 Promote the mental health of young children. health record and personal health information
4.2 Improve and expand school mental health systems.
From the Presidents New Freedom Commission on Mental Health, 2003. Retrieved May 31, 2005, from http://www.whitehouse.gov/news/

Occupational Therapy in the Promotion defines health promotion, discusses the need to address
of Health and the Prevention of Disease health disparities, describes levels of prevention, and
and Disability Statement details the role of occupational therapy at the commu-
nity and population levels. A particularly useful aspect
The AOTA supports and encourages the development
of this official document is the discussion of Wilcocks
of occupation-based health promotion and disease/
(1998) constructs of occupational imbalance, occupa-
disability prevention services and the involvement of
tional deprivation, and occupational alienation and
occupational therapy practitioners in interdisciplinary
their relationship to health promotion.
health promotion efforts. The document Occupational
Three critical roles for occupational therapy in
Therapy Services in the Promotion of Health and
health promotion are identified:
the Prevention of Disease and Disability (Scaffa, Van
Slyke, & Brownson, 2008) serves as the professions Promoting healthy lifestyles for all clients/
official document on health promotion. This document patients, their caregivers, and their families
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90 SECTION I Foundations and Key Concepts

Emphasizing occupation as an essential compo- from across the United States and Canada to form the
nent of prevention strategies and complementing Task Force on Occupation in Societal Crises (Task
health promotion services provided by experts in Force). The goal of the Task Force was to delineate the
other professions through the application of occu- influence of occupation during times of societal crisis
pational therapy principles and define the role of occupational therapists and occu-
Expanding occupational therapy interventions pational therapy assistants in disaster planning, response,
from a focus on individuals to include health and recovery.
promotion efforts with groups, organizations, com- The Task Force produced numerous publications,
munities, and policymakers (Scaffa et al., 2008) including McColls (2002) article Occupation in
Stressful Times which was published in the American
The statement lists a variety of potential health
Journal of Occupational Therapy. Other Task Force
promotion interventions at the organizational, commu-
members wrote articles that were published on the
nity, population, governmental, and policy levels. In
AOTF website. In addition, the librarian of the Wilma
addition, the document provides case studies to illustrate
West Library assembled a Resource Note, which
the application of health promotion principles in occupa-
served as a bibliography of references on the subject.
tional therapy practice. Occupational therapys unique
Pi Theta Epsilon, in collaboration with the Task Force,
contribution to health promotion and disease/disability
sponsored two sessions at the AOTA Annual Confer-
prevention is the professions focus on occupational
ence. The first, in 2003, featured a panel of experts
capabilities, skills, habits, roles, and routines, as well as
who outlined the federal, state, and local systems
its expertise in modifying environments for optimal,
responsible for responding to natural and technologi-
healthy, and safe occupational performance.
cal disasters. Panelists urged the occupational therapy
Occupation in Societal Crises Task Force audience to become involved in disaster planning in
their communities (AOTF, 2003). The second confer-
Shortly following the terrorist attacks of September 11,
ence session, held in 2005, described the role of occu-
2001, the president of the American Occupational
pational therapy practitioners in disaster planning,
Therapy Foundation (AOTF) appointed practitioners
response, and recovery. Over 100 practitioners
attended and, in small work groups, brainstormed
Implications for Occupational Therapy occupational therapy responses to several different
disaster scenarios.
Although occupational therapy can make a signifi- The AOTF Task Force collaborated with the AOTA
cant contribution to health promotion practice, it is Commission on Practice to develop an official docu-
important to acknowledge and respect the roles
and contributions of other health promotion service ment on the professions role in disasters. This docu-
providers, including health educators, public health ment is based on information gathered from focus
personnel, nutritionists, exercise physiologists, and groups, practitioners, and literature from the disaster
others. In order to demonstrate the efficacy of occu- management field. In November 2005, the Represen-
pational therapy in health promotion, it is critical that tative Assembly of the AOTA approved an official
energy and resources are directed at
concept paper titled Occupational Therapys Role in
identifying occupational factors that impact health Disaster Preparedness, Response and Recovery. The
and wellbeing;
developing assessment tools that measure these Task Forces ultimate goal is to develop a network
factors; of practitioners who are trained to respond effectively
evaluating occupation-based health promotion to disasters. Occupational therapy professionals are
services in a variety of settings with a variety of uniquely prepared to address the special needs of the
populations; and elderly and individuals with disabilities before, dur-
documenting the effectiveness and cost benefits
of occupational therapy involvement in health ing, and after disasters. In 2004, former President
promotion efforts. George W. Bush issued the executive order Individu-
als with Disabilities in Emergency Preparedness. The
Many of the prevalent social problems of today
have significant health components, for example, order is designed to enhance the nations disaster
homelessness, substance abuse, mental illness, vio- response for persons with disabilities and begins by
lence, and accidents. These social problems can be recognizing the special needs of persons with disabil-
addressed from a prevention and health promotion ities in the planning process. The order established a
perspective. Occupational therapy is uniquely posi- coordinating council within the Department of
tioned to provide essential and tangible responses in
these areas. Homeland Security to address these concerns (White
House, 2004).
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Chapter 4 Public Health Principles, Approaches, and Initiatives 91

Implications for Occupational Therapy from a variety of related fields. This review should be
extensive and include sources that may at first seem
The Health Resources and Services Administration unrelated to occupational therapy. For example, public
(HRSA) of the federal government funds the Bioter- health experts found information from geographic
rorism Training & Curriculum Development Program information systems and data from police reports con-
(BTCDP). This grant program funds continuing educa- cerning pedestrian injury rates and location of occur-
tion and curriculum development for training health
professionals in bioterrorism response. Recently, rence useful in studying child pedestrian injuries and
HRSA expanded its focus to include all-hazards developing tailored preventive strategies (Braddock et al.,
public health emergencies. 1994). This type of data can assist occupational thera-
In 2005, HRSA convened a series of focus groups pists employed in the school system to gain support for
to discuss the role of the allied health (AH) profes- developing a safety program targeting needs and safety
sions in disaster planning and response. Several
recommendations for action emerged from these risks of students and families. Data such as this would
meetings, including the need to also be important to consider in the development
develop a standardized set of basic core compe-
of school-sponsored walking programs designed to
tencies in allied health and standardized metrics to increase physical activity.
evaluate performance; According to Wilcock, the primary impediment keep-
identify discipline-specific competencies that ing the profession from reaching its potential contribu-
reflect the role of the discipline in a public health tion to population health is the dominance of the idea of
emergencythis requires role delineation and
the individual within the profession and the more or
differentiation of disaster roles from traditional roles;
create training opportunities that lead to nationally less exclusive focus on disability and handicap (2003,
recognized certification; p. 43). One way to change this thinking is to increase par-
incorporate mental health issues into all aspects ticipation in interdisciplinary, population-based health
of training; and education, research, and prevention activities. The
conduct research regarding the role of AH professions profession remains insular and focused on its perceived
in disasters.
ability to do it alland to do it alone, which fails
Specific ideas regarding training included the need to honor its history and is a costly disservice to society.
to develop multiple layers of education, the importance
of understanding chains of command, emergency The governmental reports and other initiatives described
response structure, and terminology. Focus group in this chapter can provide significant guidance on
members suggested requiring that all AH professionals the interdisciplinary, population-based health education,
obtain basic disaster training in the National Incident research, and prevention activities mentioned above.
Management System (NIMS) and participate in one When the profession is ready to routinely seek interdisci-
training exercise/drill annually. These recommenda-
tions are all relevant for occupational therapy practi- plinary opportunities, the true potential of occupational
tioners. Concerns were expressed regarding the lack therapys contribution to public health and society will
of disaster response training requirements in AH be realized.
accreditation standards, shortage of experienced This chapter encourages the involvement of occu-
instructors to teach the competencies, the difficulty pational therapy practitioners in interdisciplinary
of incorporating this content into already overflowing
curricula, and the need for real-life experiences to public health initiatives and research by reviewing
evaluate student/practitioner performance of compe- the history of public health, key governmental and
tencies. These challenges must be addressed if occu- nongovernmental reports, and national and interna-
pational therapy is to define its place in all-hazards tional perspectives on health and wellbeing. This
public health emergency planning, response, and foundational knowledge, together with the data in
these and future reports, will allow occupational ther-
apists and occupational therapy assistants to advocate
for the polices and programs needed to enhance public
Conclusion health in broader population and interdisciplinary
Governmental reports and initiatives such as those ventures.
described above can be instrumental in providing data The belief that occupation can be health-enhancing
and ideas to occupational therapists and occupational led to the development of the concept of preventive
therapy assistants seeking funds to develop health- occupation. Scaffa and colleagues (2001) defined pre-
promotion programs. These reports summarize work ventive occupation as the application of occupational
and knowledge from a variety of disciplines. An addi- science in the prevention of disease and disability and
tional step beyond reviewing reports on the subject of the promotion of health and wellbeingof individuals
interest is to review data and evidence-based research and communities through meaningful engagement in
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92 SECTION I Foundations and Key Concepts

occupations (p. 44). In 2006, AOTA adopted a state- 4. What are the occupational therapy-specific compe-
ment on health disparities that declares, Occupational tencies needed for all-hazards public health
therapy is well positioned to intervene with individuals emergency planning, response, and recovery?
and communities to limit the effects of health dispari- 5. Does the addition of occupational therapy person-
ties on participation in meaningful occupations nel to interdisciplinary health promotion programs
(Braveman, 2006, 1). The new public health approach enhance the overall effectiveness of those programs
shares a common goal with occupational therapya impact on community health?
commitment to social activism and advocacy. In addi-
tion, practitioners in these disciplines understand the
impact of the social and physical environments on Acknowledgments
health. It should be easy to find willing partners
with whom to join forces. We cannot solve all prob- The authors wish to express their appreciation to the
lems of poverty and injustice, but we can improve following individuals who assisted with the preparation
survival and quality of life, step by step, one acre at a of this chapter: Frederick D. Reitz, Gar Wing Tsang,
time, to achieve wondrous miracles (Tulchinsky & and Grace E. Wenger.
Varavikova, 2000, p. 3).

For Discussion and Review
1. What are the similarities and differences between Agency for Healthcare Research and Quality. (2005). National
healthcare disparities report. Retrieved March 13, 2006,
occupational therapy and public health in terms of from http://www.ahrq.gov/qual/nhdr05/nhdr05.htm.
ideology, goals, and approaches? American Association of Community Colleges. (2004).
2. How might occupational therapy provide preven- Bridges to healthy communities 2005. Retrieved November
tive, occupation-based interventions to individuals, 28, 2004, from http://www.aacc.nche.edu/Content/
families, groups, and communities? NavigationMenu/ResourceCenter/Projects_Partnerships/
3. Briefly describe an occupational therapy health Current/BridgestoHealthyCommunities/AbouttheProject/
promotion intervention and the supporting U.S.
and international documentation. American College Health Association. (2002). Healthy Campus
2010: Making it happen. Baltimore: Author.
4. Identify and discuss aspects of the AOTAs Frame-
American College Health Association. (2004). ACHA-National
work that support the role of occupational therapy College Health Assessment. Retrieved November 28, 2004,
in health promotion. from http://www.acha.org/projects_programs/assessment.cfm.
5. Read the AOTA official document on health promo- American Occupational Therapy Association. (1993). Core
tion and develop three occupational therapy strategies values and attitudes of occupational therapy practice.
for addressing one of the public health challenges American Journal of Occupational Therapy, 47, 108586.
identified in Tables 4-3 or 4-4. American Occupational Therapy Association. (2003). American
6. Review one of the national health documents Occupational Therapy Association/FAST project: Role of
described in this chapter, identify a target population, occupational therapists in violence prevention [Executive
Summary]. Retrieved November 29, 2004, from
and briefly outline three possible occupational http://www.aota.org/members/area2/limnks/link36.asp.
therapy health promotion interventions that could
American Occupational Therapy Association. (2004). Occupa-
be suggested to that population. tional therapys commitment to nondiscrimination and inclu-
sion. American Journal of Occupational Therapy, 58, 668.
American Occupational Therapy Association. (2005). Occupa-
Research Questions tional therapy code of ethics (2005). American Journal
Occupational Therapy, 59(6), 63942.
1. Does the addition of occupational therapy interven- American Occupational Therapy Association. (2008).
tions in health promotion programs enhance program Occupational therapy practice framework: Domain and
effectiveness? processes. American Journal of Occupational Therapy,
56, 60939.
2. What are the effects of brief health promotion
American Occupational Therapy Association. (2009, March 4).
interventions in traditional occupational therapy OTA programsAccredited. Retrieved March 7, 2009, from
settings? http://www.aota.org/nonmembers/area13/links/link29.asp.
3. What are the effects of brief, repeated, developmen- American Occupational Therapy Foundation. (2003). Plenary
tally graded health promotion interventions in session draws attention to disaster planning. AOTF Connec-
school-based occupational therapy settings? tion, 10(2), 7.
1193_Ch04_070-095.qxd 6/8/09 5:51 PM Page 93

Chapter 4 Public Health Principles, Approaches, and Initiatives 93

American Public Health Association. (2003). Growth of Institute of Medicine. (1988). The future of public health.
international health: An analysis and history. Retrieved Washington, DC: National Academies Press.
March 13, 2006, from http://www.apha.org/wfpha/pdf/ Institute of Medicine. (2003). Unequal treatment: Confronting
InternationalHealth Book1.pdf. racial and ethnic disparities in health care. Washington, DC:
Best, J., & Cameron, R. (1986). Health behavior and health National Academies Press.
promotion. American Journal of Health Promotion, 1, 4856. Johnson, J. (1986). Wellness: A context for living. Thorofare,
Braddock, M., Lapidus, G., Cromley, E., Cromley, R., Burke, NJ: SLACK.
G., & Banco, L. (1994). Using a geographic information Kielhofner, G. (2004). The development of occupational ther-
system to understand child pedestrian injury. American apy knowledge. In Conceptual foundations of occupational
Journal of Public Health, 84(7), 115861. therapy (3d ed., pp. 2763). Philadelphia: F. A. Davis.
Braveman, B. (2006). AOTAs Statement on Health Disparities. Kronenberg, F., Sim-Algado, S., & Pollard, N. (Eds.). (2005).
American Journal of Occupational Therapy, 60(6), 670. Occupational therapy without borders: Learning from the
Breines, E. (1986). Origins and adaptations. Lebanon, NJ: spirit of survivors. New York: ELSEVIER, Churchill
Geri-Rehab. Livingstone.
Brownson, C. A., & Scaffa, M. E. (2001). Occupational ther- Lalonde, M. A. (1974). A new perspective on the health of
apy in the promotion of health and the prevention of disease Canadians. Ottawa: Ministry of National Health and
and disability statement. American Journal of Occupational Welfare.
Therapy, 55(6), 65660. Lasker, R. D., & the Committee on Medicine and Public
Bush, G. (2002, April 22). Executive Order: Presidents Health. (1997). Medicine & public health: The power of
New Freedom Commission on Mental Health. Retrieved collaboration. New York: The New York Academy of
May 31, 2005, from http://www.whitehouse.gov/news/ Medicine.
releases/2002/04/20020429-2.html. Life Online. (n.d.) MillenniumTop 100 events, No. 6 1882 the
Centers for Disease Control and Prevention. (1999). Ten great germ theory of disease. Retrieved November 28, 2004, from
public health achievements: United States, 19001999. http://www.life.com/Life/millennium/events/06.html.
Morbidity and Mortality Weekly Report, 48(12), 24143. Lyons, A., & Petrucelli, R. (1987). Medicine: An illustrated
Centers for Disease Control and Prevention, National Center history. New York: Abradale Press.
for Health Statistics. (2006). Health, United States, McColl, M. A. (2002). Occupation in stressful times. American
2006 (p. 29). Washington, DC: Government Printing Office. Journal of Occupational Therapy, 56(3), 35053.
Centers for Disease Control and Prevention, National Center National Library of Medicine. (2006). Map of Washington,
for Injury Prevention and Control. (2004a). The Injury D.C., showing projected harbor improvement and system of
Centers niche in preventing youth violence, CDC Injury drainage, 1881. Retrieved September 8, 2006, from
Research agendaPreventing youth violence. Retrieved http://wwwihm.nlm.nih.gov/cgi-bin/gw_44_3/chameleon.
January 18, 2008, from http://www.cdc.gov/ncipc/
pubres/research_agenda/09_youthviolence.htm. OConnor-Fleming, M. L., & Parker, E. (1995). Health promo-
tion principles and practice in the Australian context. New
Centers for Disease Control and Prevention, National Center South Wales, Australia: Allen & Unwin.
for Injury Prevention and Control. (2004b). The Injury Cen-
ters research priorities, CDC Injury Research agenda Partnership to Promote Healthy Eating and Active Living.
Preventing youth violence. Retrieved January 18, 2008, (2003). America on the MoveTM. Retrieved November 3,
from http://www.cdc.gov/ncipc/pubres/research_agenda/ 2003, from http://www.americaonthemove.org/index.asp.
09_youthviolence.htm. Peloquin, S. M. (1989). Looking backMoral treatment:
Colonial Williamsburg Foundation. (2004). Public hospital Contexts reconsidered. American Journal of Occupational
exhibit. Colonial Williamsburg, VA: Author. Therapy, 43, 53744.
Ebb, E., & Haiman, S. (1990). Enriching the fieldwork II expe- Pinel, P. (1948). Medical philosophical treatise on mental
rience: A recruitment strategy for psychosocial occupational alienation (S. Licht, Trans). In S. Licht (Ed.), Occupational
therapy. Occupational Therapy in Mental Health, 10, 2946. therapy sourcebook (pp. 1924). Baltimore: Williams and
Wilkins. (Original work published 1801.)
Gandy, J. (2004). Trends and issues in education [PowerPoint
presentation]. Retrieved October 3, 2005, from http:// Presidents New Freedom Commission on Mental Health.
www.aota.org. (2003). Achieving the promise: Transforming mental health
care in America. Executive summary (DHHS Pub. NO
Geller, J. L. (2000). The last half-century of psychiatric SMA-0303831). Rockville, MD: DHHS.
services as reflected in psychiatric services. Psychiatric
Services, 51(1), 4167. Reiser, S. J. (1997). Topics for our times: The medicine/public
health initiative. American Journal of Public Health, 87(7),
Goraya, A., & Scambler, G. (1998). From old to new public 109899.
health: Role tensions and contradictions. Critical Public
Health, 8(2), 14151. Reitz, S. M. (2003, June 2223). Rural interdisciplinary health
promotion service learning training. Lecture presented
Green, L. W., & Kreuter, M. W. (1991). Health promotion at the Western Maryland Area Health Education Center,
planning: An educational and environmental approach Cumberland, MD.
(2d ed.). Mountainview, CA: Mayfield.
Reitz, S., Scaffa, M., & Merryman, M. (2004). Examples of
Green, L. W., & Kreuter, M. W. (1999). Health promotion health promotion programming in the U.S. [Figure]. Used
planning: An educational and ecological approach (3d ed.). by S. M. Reitz in Occupational therapy in health
Mountainview, CA: Mayfield. promotionMoving into a new era, invited plenary session,
1193_Ch04_070-095.qxd 6/8/09 5:51 PM Page 94

94 SECTION I Foundations and Key Concepts

Occupational Therapy Symposium 2004Achieving Health U.S. Department of Health and Human Services. (1994).
and Wellness through Occupation: From Theory to Practice, Public health in America. Retrieved October 1, 2006, from
Hong Kong, February 28, 2004. http://www.health.gov/phfunctions/public.htm.
Reitz, S., Scaffa, M., & Pizzi, M. (2004). Relationship between U.S. Department of Health and Human Services. (1999). Mental
health promotion interventions & wellness from an occupa- health: A report of the Surgeon General. Rockville, MD:
tional therapy perspective [Figure]. Used in Health and U.S. Department of Health and Human Services, Substance
wellness through occupation: The American perspective, Abuse and Mental Health Services Administration, Center
invited open seminar, Hospital Authority, Hong Kong, for Mental Health Services, National Institutes of Health,
February 27, 2004. National Institute of Mental Health.
Roemer, M. I. (2000). Foreword. In T. H. Tulchinsky & U.S. Department of Health and Human Services. (2000a).
E. A.Varavikova, The new public health: An introduction Healthy People 2010: Understanding and improving health
for the 21st century (pp. xixxxi). San Diego, CA: (2d ed.). Washington, DC: Government Printing Office.
Academic Press. U.S. Department of Health and Human Services. (2000b).
Sandstrom, R. W., Lohman, H., & Bramble, J. D. (2003). Tracking Healthy People 2010. Washington, DC: Government
Health services: Policy and systems for therapists. Upper Printing Office. Retrieved November 28, 2004, from
Saddle River, NJ: Prentice Hall. http://www.healthypeople.gov/Document/tableofcontents
Scaffa, M. E., Desmond, S., & Brownson, C. A. (2001). Public .htm#tracking.
health, community health, and occupational therapy. In U.S. Department of Health and Human Services. (2001a).
M. E. Scaffa (Ed.), Occupational therapy in community-based Healthy people in healthy communities: A community plan-
practice settings (pp. 3550). Philadelphia: F. A. Davis. ning guide using Healthy People 2010. Retrieved November
Scaffa, M. E., Van Slyke, N., & Brownson, C. A. (2008). Occu- 27, 2004, from http://www.healthypeople.gov/Publications/
pational therapy services in the promotion of health and the HealthyCommunities2001/healthycom01hk.pdf.
prevention of disease and disability, American Journal of U.S. Department of Health and Human Services. (2001b).
Occupational Therapy 62(6), 694703. Youth violence: A report of the Surgeon General. Rockville,
Schwartz, K. B. (2003). The history of occupational therapy. In MD: U.S. Department of Health and Human Services,
E. B. Crepeau, E. S. Cohn, & B. A. Schell (Eds.), Willard & Centers for Disease Control and Prevention, National
Spackmans occupational therapy (10th ed., pp. 513). Center for Injury Prevention and Control; Substance Abuse
Philadelphia: Lippincott, Williams & Wilkins. and Mental Health Services Administration, Center for Mental
Health Services; and National Institutes of Health, National
Spear, P. S., & Crepeau, E. B. (2003). Glossary. In E. B. Crepeau, Institute of Mental Health. Retrieved January 18, 2008,
E. S. Cohn, & B. A. Schell (Eds.), Willard & Spackmans from http://www.surgeongeneral.gov/library/youthviolence/
occupational therapy (10th ed., pp. 102535). Philadelphia: youvioreport.html
Lippincott, Williams & Wilkins.
U.S. Department of Health and Human Services. (2003a).
Thornton, T. N., Craft, C. A., Dahlberg, L. L., Lynch, B. S., & Healthy People 2010: Progress reviewsHealth
Baer, K. (2002). Best practices of youth violence preven- communication. Retrieved November 28, 2004, from
tion: A sourcebook for community action (rev.). Atlanta: http://www.healthypeople.gov/data/2010prog/focus11/.
Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control. Retrieved U.S. Department of Health and Human Services. (2003b). New
November 28, 2004, from http://www.cdc.gov/ncipc/dvp/ Freedom Initiative. Retrieved June 4, 2005, from
bestpractices.htm. http://www.hhs.gov/new freedom/init.html.
Timmreck, T. C. (1995). Planning, program development, and U.S. Department of Health and Human Services. (2003c). New
evaluation: A handbook for health promotion, aging, and Freedom Initiative, Executive Order 13217. Retrieved May 28,
health services. Boston: Jones and Bartlett. 2005, from http://www.hhs.gov/newfreedom/eo13217.html.
Tulchinsky, T. H., & Varavikova, E. A. (2000). The new public U.S. Department of Health and Human Services. (2004). Healthy
health: An introduction for the 21st century. San Diego, People 2010: Progress reviews. Retrieved November 27,
CA: Academic Press. 2004, from http://www.hhs.gov/about/hhshist.html and
University of Southern California, Department of Occupational #2010.
Therapy & Occupational Science. (n.d.) Faculty practice.
Retrieved July 23, 2008, from http://www.usc.edu/schools/ U.S. Department of Health and Human Services. (2005).
ihp/ot/faculty_practice/. Historical highlights. Retrieved September 8, 2006, from
U.S. Department of Health and Human Services. (1979).
Healthy People: Surgeon Generals report on health promo- U.S. Department of Health and Human Services. (2006).
tion and disease prevention. Washington, DC: Government Foreword. Healthy People 2010 midcourse review. Retrieved
Printing Office. January 18, 2008, from http://www.healthypeople.gov/Data/
U.S. Department of Health and Human Services. (1980).
Promoting health/preventing disease: Objectives for the U.S. Department of Justice. (2000). ADA tenth anniversary:
nation. Washington, DC: Government Printing Office. Faces of the ADA. Retrieved September 10, 2006, from
U.S. Department of Health and Human Services. (1990).
Healthy People 2000: National health promotion and U.S. Department of Justice. (2006). ADA signing ceremony.
disease prevention objectives. Washington, DC: Government Retrieved September 10, 2006, from http://www.usdoj.gov/
Printing Office. crt/ada/videogallery.htm.
1193_Ch04_070-095.qxd 6/8/09 5:51 PM Page 95

Chapter 4 Public Health Principles, Approaches, and Initiatives 95

Vogel, V. J. (1970). American Indian medicine. Norman: World Health Organization. (1997a). Jakarta declaration on
University of Oklahoma Press. leading health promotion into the 21st century. Retrieved
White House. (2004, July 22). Executive order: Individuals May 29, 2005, from http://www.who.int/hpr/NPH/docs/
with disabilities in emergency preparedness. Press release. jakarta_declaration_en.pdf.
Retrieved June 3, 2005, from http://www.whitehouse.gov/ World Health Organization. (1997b). Twenty steps for develop-
news/releases/2004/07/print/20040722-10.html. ing a healthy cities project. Retrieved February 26, 2006,
White House Domestic Policy Council. (2004). The presidents from http://www.euro.who.int/healthy-cities/introducing/
new freedom initiative for people with disabilities: The 20050202_2.
2004 progress report, Executive summary. Retrieved World Health Organization. (2001). The international classifi-
November 24, 2006, from http://www.whitehouse.gov/ cation of functioning, disability, and health (ICF). Geneva,
infocus/newfreedom/toc 2004.html. Switzerland: Author.
Wilcock, A. A. (1998). An occupational perspective of health. World Health Organization. (2004a). Background for healthy
Thorofare, NJ: SLACK. cities network. Retrieved November 27, 2004, from
Wilcock, A. A. (2003). Occupational therapy practice: Section http://www.euro.who.int/healthy-cities/CitiesAndNetworks/
II Population interventions focused on health for all. In 20020111_1.
E. B. Crepeau, E. S. Cohn, & B. A. Schell (Eds.), Willard & World Health Organization. (2004b). The precautionary
Spackmans occupational therapy (10th ed., pp. 3045). principle: Protecting public health, the environment and the
Philadelphia: Lippincott, Williams & Wilkins. future of our children. Retrieved February 25, 2006, from
Wilcock, A., & Whiteford, G. (2003). Occupation, health http://www.euro.who.int/eprise/main/WHO/Progs/HMS/
promotion, and the environment. In L. Letts, P. Rigby, & D. MainActs/20040129_1.
Stewart (Eds.), Using environments to enable occupational World Health Organization. (2005a). About WHO. Retrieved
performance (pp. 5570). Thorofare, NJ: SLACK. May 30, 2005, from http://www.who.int/about/en/.
World Federation of Occupational Therapists. (2004). WFOT World Health Organization. (2005b). Healthy cities and urban
position paper on community based rehabilitation. governance. Retrieved February 26, 2006, from http://www
Retrieved March 6, 2006, from http://www.wfot.org/ .euro.who.int/healthy-cities.
Document_Centre/default.cfm. World Health Organization. (2006a). Working for health: An
World Health Organization. (1947). Constitution of the World introduction to the World Health Organization. Geneva:
Health Organization. Chronicle of the World Health Organi- Author.
zation, 1(1), 2940. World Health Organization. (2006b). WHO regional offices.
World Health Organization. (1948, June). Official records of Retrieved February 26, 2006, from http://www.who.int/
the World Health Organization, No. 2. Proceedings and about/regions/en/index.html.
final acts of the International Health Conference held in World Health Organization. (2006c). Depression. Retrieved
New York from 19 June to 22 July 1946. Retrieved March 16, 2006, from http://www.who.int/mental_health/
December 4, 2004, from http://whqlibdoc.who.int/hist/ management/depression/definition/en/.
Zwelling, S. S. (1985). Quest for a cure: The public hospital in
World Health Organization. (1986). Ottawa charter for health Williamsburg, Virginia, 17731885. Williamsburg, VA:
promotion. Retrieved December 4, 2004, from Colonial Williamsburg Foundation.
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Chapter 5

Cultural and Sociological Considerations

in Health Promotion
Bette Bonder

I do not want my house to be walled in on all sides and my windows to be stuffed. I

want the cultures of all the lands to be blown about my house as freely as possible. But I
refuse to be blown off my feet by any.
Mahatma Gandhi (18691948)

Learning Objectives
This chapter is designed to enable the reader to:
Define culture, cultural competency, race, ethnic- rates of illness and disability;
ity, socioeconomic status, enculturation, accultur- perceptions of health, illness, and disability;
ation, and spirituality. performance areas;
Describe the impact of culture and socioeco- performance patterns;
nomic status on health and health disparities. performance skills; and
Discuss reasons for addressing cultural and performance contexts, activity demands,
socioeconomic factors in designing health and client factors.
promotion interventions. Discuss implications for design of culturally
Describe the ways in which culture and relevant preventive interventions in occupational
socioeconomic status affect behavior in terms of therapy.
health behaviors;

K e y Te r m s
Acculturation Ethnicity Internal locus of Socioeconomic status
Cultural competency Explanatory model control Spirituality
Culture External locus of Race
Enculturation control Religion

Introduction core values of occupational therapy practitioners are in

harmony with the desire described by Alvord and Van
Since the inception of the occupational therapy profes- Pelt (1999):
sion, occupational therapists have been aware of the
importance of culture in the occupational lives of their Navaho healers use song to carry words of the Beauty
clients (Dunton, 1915). In the past 25 years, occupa- Way; the songs provide a blueprint for how to live a
tional therapy literature has increasingly addressed the healthy, harmonious, and balanced life. I would like
centrality of culture to occupational choice and satis- to create such a pathway between cultures so that
faction with occupational patterns (cf. Barney, 1991; people can walk across and see the wonders on the
Dillard et al., 1992; Iwama, 2004; Levine, 1984). The other side. (p. 16)
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Chapter 5 Cultural and Sociological Considerations in Health Promotion 97

This chapter will explore the definitions of culture and see it but have a much more difficult time providing
socioeconomic status, and the ways in which these a concrete definition. They are not alone in this, as
affect beliefs and behaviors related to occupations, researchers and theorists have similar difficulty. Kuper
health, illness, and disability. Strategies for addressing (1999), an anthropologist, indicates in its most general
cultural and socioeconomic factors in the occupational sense, culture is simply a way of talking about collec-
therapy process will also be discussed. tive identities (p. 3). The U.S. Department of Health
In the United States, socioeconomic factors are and Human Services (USDHHS), indicates that cul-
strongly associated with culture, particularly when cul- ture refers to integrated patterns of human behavior that
ture is defined based on race or ethnicity. In community include language, thoughts, communications, actions,
health and health care, there is substantial evidence that customs, beliefs, values, and institutions of racial,
socioeconomic factors affect individual health, access ethnic, religious, or social groups (2000, p. 80865). A
to care, and outcomes of care received (cf. Bowman variety of definitions are offered in the occupational
& Wallace, 1990; Hakansson et al., 2003); therefore, therapy literature, a selection of which is detailed in
effective interventions must address both culture and Content Box 5-1.
socioeconomic factors. While these definitions vary somewhat, they all
The evidence of the impact of culture and socioeco- suggest that culture is shared among members of
nomic status on health and wellbeing is sufficiently a particular group; is learned not inherent; is localized
compelling that the professional culture of occupa- geographically; is patterned in the sense that it
tional therapy clearly reflects their importance. In describes roles, behaviors, and values; and has some
1999, the Representative Assembly of the American element of constancy although it may change over
Occupational Therapy Association (AOTA, 2004) time (Bonder, Martin, & Miracle, 2002, 2004). Thus,
approved a statement regarding support for inclusion culture contributes strongly to beliefs and behaviors of
and nondiscrimination. That statement has been revised individuals.
and is now titled Occupational Therapys Commitment Another important attribute of culture is that it
to Nondiscrimination and Inclusion (AOTA, 2004). emerges in interaction (Bonder et al., 2004; Tedlock &
These beliefs are further supported by the Occupa- Mannheim, 1995). This means that culture is not some-
tional Therapy Practice Framework: Domain and thing that is concrete and fixed in the environment.
Process (AOTA, 2008), which indicates occupational Rather, it is an element of relationships among people
therapists and occupational therapy assistants recog-
nize that engagement in occupation occurs in a variety
of contexts (cultural, physical, social, personal, tempo-
ral, spiritual, virtual) (p. 612). In addition, the AOTA
Occupational Therapy Code of Ethics (2005) states Content Box 5-1
that occupational therapy personnel will recognize
and appreciate the cultural components of economics, Sample of Definitions of Culture
geography, race, ethnicity, religious and political fac- and Cultural Context From the
tors, marital status, age, sexual orientation, gender Occupational Therapy Literature
identity, and disability of all recipients of their ser-
A state of manners, taste, and intellectual devel-
vices (p. 639). opment at a time or place. It is the ideas, customs,
While it seems self-evident that culture and socioeco- arts, etc. of a given people at a given time
nomic status should be considerations in care, acting on (Baptiste, 1988, p. 180).
that belief is no simple matter. This chapter provides Values, beliefs, customs and behaviors that are
definitions and descriptions important to efforts to passed on from one generation to the next
(Christiansen & Baum, 1997, p. 61).
ensure that culture and socioeconomic status are accu- An abstract concept that refers to learned and
rately identified and addressed in designing occupation- shared patterns of perceiving and adapting to the
based preventive and health-promoting interventions. world (Fitzgerald, Mullavey-OByrne, & Clemson,
1997, p. 1).
Customs, beliefs, activity patterns, behavior stan-
Defining Terms dards, and expectations accepted by the society
of which the [client] is a member. Includes ethnic-
Defining terms to facilitate understanding and commu- ity and values as well as political aspects, such as
nication is an important first step. A number of con- laws that affect access to resources and affirm
structs require explanation before any meaningful personal rights. Also includes opportunities for
dialogue can occur. We begin by considering culture. education, employment, and economic support
(AOTA, 1994, p. 1054) (AOTA, 2008, p. 670).
Most people probably believe they know it when they
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98 SECTION I Foundations and Key Concepts

and groups. This is why it is not possible to identify much higher incidence among individuals from some
ones culture from looking at an individual. Thus, cul- Hispanic backgrounds than for other groups. Other
ture is not race, nor is it any other biological attribute of groups are at risk of receiving substandard care, as in
individuals. Rather it is socially constructed during the case of African Americans with heart disease.
communication. Although these associations are well documented, they
Because race is so often used as a proxy for culture are not well explained.
(Wang & Sue, 2005), it is important to examine this Racial or ethnic labels tend to obscure important dif-
construct. The National Research Council (NRC) ferences. The label Asian, for example, includes such
defines race as a combination of physical characteris- diverse groups as Japanese Americans and Hmong. The
tics along with individual, group, and social attributes first group is relatively similar socioeconomically to
(1997, p. 2). Ethnicity, by the same groups definition, the majority culture in the United States. It includes
refers to individual, group, and social attributes in the some individuals recently arrived to this country and
absence of common physical features that lead to cate- others whose families have lived in the United States
gorization of individuals into a particular group (NRC, for so long that they have only a nominal affiliation
1997). And while some hold that race is genetic, recent with the country from which their ancestors came.
scientific advances in the understanding of human The Hmong, on the other hand, have come to the
heredity suggest that genetic differences among racial United States in substantial numbers only in the last
groups are tiny (Wang & Sue, 2005). Race and ethnic- generation or so (Fadiman, 1997). Those who arrived
ity are increasingly perceived as entirely social (i.e., not here initially were refugees from a war-torn region in
biological) constructs. For example, Sacks observes, which they had been completely dispossessed. They
arrived with no economic resources, no ability to speak
The study of the deaf shows us that much of what is
English, and no education in the formal Western sense.
distinctively human in usour capacities for language,
This first generation settled in several communities in
for thought, for communication, and culturedo not
California and Minnesota, where they struggled to
develop automatically in us, are not just biological
make a life for themselves and, at the same time,
functions, but are, equally, social and historical in
changed the dynamics of the communities to which
origin; that they are a giftthe most wonderful gift
they immigrated. Health and social service providers
from one generation to another. (1989, p. xi)
experienced new challenges as a result of this influx.
It is possible that race and ethnicity emerged as cate- Another complicating factor in an attempt to under-
gorical markers in health care, because several health stand how race and ethnicity (and other cultural vari-
conditions, such as sickle-cell anemia and Tay-Sachs dis- ables) affect health is the interaction of these variables
ease, are clearly clustered in particular groups (Arnason, with economic considerations. Socioeconomic status
Sigurgislason, & Benedikz, 2000). This observation has has been defined as categorization based on education,
given weight to race and ethnicity as constructs, although income, wealth, and position in the social hierarchy
current explanations of this clustering suggest they are (Krieger, Williams, & Moss, 1997). Although the
found most often in particular groups because of histori- United States is often presented as a classless society,
cal proximity of groups of individuals at a time when differentials in power, status, and economic resources
contact between groups was limited and because they clearly exist (Mills, 1958/2005), which affects health,
conferred some unique survival benefit in those geo- functional abilities, and health care (Smedley et al.,
graphic areas (Wang & Sue, 2005). For example, sickle- 2003). Studies of child development have found that
cell anemia, a condition found almost exclusively in socioeconomic status affects childrens hand size
African and African American groups, appears to provide and strength, praxis, and other visuomotor factors
some protection against malaria. Thus, race and ethnicity (Bowman & Wallace, 1990). Culture and socioeco-
in health care may have become proxies for expectations nomic status, while clearly implicated in health status
about the probability that individuals might be suscepti- and outcomes of care, represent a complicated set of
ble to specific health conditions. interacting considerations.
Race and ethnicity are also strongly correlated with An often overlooked fact is that everyone has culture,
access to and outcomes of health care (Smedley, Stith, ethnicity, and socioeconomic status. Just as clients bring
& Nelson, 2003). In fact, a recently published Institute cultural beliefs and values to health-care encounters,
of Medicine report (Smedley et al., 2003) has focused providers of care bring cultural beliefs and values to the
national attention on a growing problemthat there is situation. Professions are themselves cultures (Krusen,
clear and compelling evidence that individuals from 2003). Consider the beliefs conveyed in occupational
particular racial and ethnic backgrounds are at high risk therapy education about the kinds of interventions that
of certain diseases. Diabetes, for example, occurs at a will restore health or prevent dysfunction. Compare
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Chapter 5 Cultural and Sociological Considerations in Health Promotion 99

those beliefs with those of surgeons. Both professions these ways, acculturation, adoption of majority cultural
are concerned with helping clients, but their beliefs values and behaviors, may have led the individual away
about how to do that differ dramatically. from the culture of origin.
Not only do all individuals have culture, but most
also have many cultures (Bonder et al., 2002) that inter- Spirituality, Religion, and Health
act with each other. An individual might identify with
all of the following: Italian American (ethnic culture), Recent occupational therapy literature has increasingly
high school student (developmental-stage culture), focused on spirituality (Belcham, 2004; Canadian Asso-
Catholic (religious culture), hearing-impaired (physical- ciation of Occupational Therapists, 1997; 2002; Mayers,
status culture), gay (gender-preference culture), and so 2004; McColl, 2003; Phillips, 2003; Townsend, De Laat,
on. This individual also has socioeconomic status (for a Egan, Thibeault, & Wright, 1999). Spirituality appears
high school student, this is typically conferred by as the central core of the Canadian Model of Occupa-
parental status) that arguably could also be considered tional Performance (CMOP), as depicted in Figure 5-1
culture; for example, middle-class suburban. and described in more detail in Content Box 5-2.
This hypothetical high school student has been Both religion and spirituality are important ele-
enculturated into multiple cultures. The process of ments of culture. Religion is defined by hyperdic-
enculturation involves learning about culture through tionary (2005a, 2) as an institution to express
direct instruction, observation, and modeling. High belief in a divine power. Specific religions, depend-
school students, for example, are particularly observant ing on their particular attributes, may well be defined
about those around them and those portrayed in the me- as cultures, since they are learned, shared, patterned,
dia. They choose their style of dress, language, and and convey values. Issues about ability to conduct re-
sometimes even their gait in an attempt to be as similar ligious rituals, participate in religious events, and
as possible to their peers. This particular student has maintain culturally prescribed religious customs
undoubtedly also learned about being an Italian Amer- (e.g., cooking particular foods, undertaking volunteer
ican through direct instruction by his or her parents, activities that are prescribed by particular religions)
stories told by grandparents, and so on. can be major concerns for individuals, families, and
This individual may have learned other cultural communities.
identities through more subtle interaction with others. Spirituality, on the other hand, is concern with
Gay high school culture is somewhat hidden, and things of the spirit (hyperdictionary, 2005b, 1). This
unless the students parents are also hearing-impaired, means that spirituality focuses on concerns about the
the student may have to actively seek out others with spirit and the divine that are not necessarily associated
hearing impairments to learn about this very well- with an established religious group or institution.
established culture (for more information about the According to Frey, Daaleman, and Peyton (2005), the
culture of individuals with hearing impairment, see term nonreligious spiritual propensity (p. 559) is some-
Sacks, 1989). times found in the literature. These authors conceptu-
Acculturation, by contrast, is the process by which alization of spirituality focuses on two factors: life
individuals relinquish aspects of their culture to acquire scheme and self-efficacy. They note that spirituality
those of the surrounding majority culture. So in the may be tied to attributes of personal meaning that may
case of the high school student previously described, or may not be tied to religious traditions (p. 560).
the grandparents may have been first-generation Italian The focus on personal meaning is echoed by the defin-
Americans who immigrated to the United States from ition proposed by the Association of Professional
Italy. They may well have chosen to live in a largely Chaplains (2001) that suggests that spirituality is an
Italian immigrant neighborhood where they could appreciation of presence and purpose that includes a
speak Italian, eat foods familiar from their country of sense of meaning (p. 81).
birth, and maintain customary behaviors. Their second- This focus on meaning is particularly noteworthy for
generation children may have learned to speak Italian occupational therapists, given the professions empha-
but chosen to speak primarily English, or they may sis on supporting the engagement of individuals and
have enjoyed Italian food, but also chosen to eat fast communities in meaningful occupations. For some,
food and steak more frequently. In addition, they may that meaning emerges through connection with some-
have had greater opportunity for educational accom- thing beyond themselves. Whether that something is
plishments that led to better paying jobs that allowed a identified as God, as in the case of religion, or a more
move to the suburbs. The third-generation high school generally stated bigger purpose, as in the case of spir-
student previously described may not speak Italian at ituality, this aspect of culture and of personal values
all and may equate Italian food solely with pizza. In all and beliefs cannot be ignored.
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100 SECTION I Foundations and Key Concepts


na Cu
tutio ltu
In sti


P ro







Cognitive Physical



Figure 5-1 Canadian Model of Occupational Performance.

From Enabling occupation: An occupational therapy perspective, by the Canadian Association of Occupational Therapists, 2002, Figure 1, p. 32. With permission.

Content Box 5-2 those who had been especially kind to the deceased
(Wicasa, 2005).
Ideas About Spirituality From the An individual can be spiritual without being reli-
Canadian Model of Occupational gious and can be religious without being spiritual. The
Performance hypothetical high school student described earlier self-
identifies as Catholic. This might imply active partici-
Innate essence of self pation in formal religious practices (e.g., Mass) or in
Quality of being uniquely and truly human
Expression of will, drive, motivation culturally Catholic events (e.g., discussion groups led
Source of self-determination and personal control by the parish priest), or it might mean simply having
Guide for expressing self been raised in a home where Catholicism was the
stated religious affiliation. Regardless of which of these
From Enabling occupation: An occupational therapy perspective, by
the Canadian Association of Occupational Therapists, 2002, Table 7, is true, the student might still be highly spiritual, not at
p. 43. With permission. all spiritual, or (most likely) somewhere between these
two poles.
In occupational therapy, both spirituality and reli-
In some cultures, it could be argued that spiritual gion have important consequences for clients choices
considerations guide all of lifes decisions, including and for outcomes of care (Beauregard & Solomon,
those about occupational choices and health behaviors 2005; Schulz, 2004; Wilding, May, & Muir-Cochrane,
(Alvord & Van Pelt, 1999). For example, many Native 2005). Research suggests that spirituality or religion
American cultures have a spiritual reverence for the has implications for outcomes of care in HIV/AIDS
stars. They believe that the Great Spirit gave the stars (Beauregard & Solomon, 2005), mental health (Wild-
power to guide humans on Earth and impart spiritual ing et al., 2005), substance abuse (Rivera-Mosquera,
blessings on them. The Milky Way is seen as a pathway 2005), chronic pain (Rippentrop, 2005), and many
for departed loved ones to reach the southern star, or other conditions.
abiding place of the dead. Star quilts are a manifesta- There is evidence that occupational therapists are
tion of this belief and are given on the first-year anniver- somewhat reluctant to address spiritual or religious fac-
sary of a loved ones death as a token of appreciation to tors (Belcham, 2004; Udell & Chandler, 2000), in part
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Chapter 5 Cultural and Sociological Considerations in Health Promotion 101

because they feel unprepared or unqualified to do so. At The Importance of Culture

the same time, there is growing awareness of the impor-
tance or centrality of these concerns in the occupational and Socioeconomic Status
lives of individuals (Collins, Paul, & West-Frasier, 2001). in Health and Health Care
Someone who believes that illness or disability is Gods
will might have very different motivation for participa- The professional culture of occupational therapy holds
tion in preventive interventions or remediation of dys- that individuals should identify goals that are meaning-
function than someone who believes that God helps ful to them and that the therapists interventions should
those who help themselves. be client-centered, assisting the individual to accom-
Ultimately, it seems likely that in working in the plish those goals (AOTA, 2008). By definition, culture
community, religious and spiritual beliefs and motiva- influences individual and group values, beliefs, and
tions must be considered (Townsend, 1997). Without behaviors. It is inevitable that understanding the culture
attention to these considerations, it is possible, perhaps of the individual or group is central to intervention. The
even probable, that interventions will not address cen- hope is that understanding and incorporating those
tral concerns of the group. Culture, including religion beliefs will improve outcomes of care. Although this
and spirituality, are vital motivating factors for both remains to be validated through careful outcomes
individuals and groups. In order to move toward cul- research, there is certainly a growing body of literature
tural competency, they must be understood and valued. to suggest that it is true.
Given demographic trends in the United States, it is
challenging to understand culture and incorporate it
into preventive and health promotion interventions.
Cultural Competency The United States has long been a magnet for immi-
The fact that culture and the factors that fall within its grants from around the world and has undergone and
sphere are so difficult to define complicates efforts to continues to undergo dramatic demographic change
achieve cultural competency. According to the Cul- (U.S. Department of Commerce, 1999). It is estimated
turally and Linguistically Appropriate Services (CLAS) that by 2070, the population will be more than 50%
standards developed by the USDHHS, Office of nonwhite, with African Americans and Hispanics mak-
the Secretary (2000), cultural competency can be ing up the largest proportion of the minority commu-
thought of as having the capacity to function effec- nity. The population of individuals from Asia is
tively as an individual and an organization within the also growing rapidly, representing a wide range of Far
context of the cultural beliefs, behaviors, and needs Eastern cultures (U.S. Census Bureau, 2000).
presented by consumers and their communities In the past decade, there has been growing aware-
(p. 80865). Unfortunately, as is the case for defini- ness that culture and socioeconomic status have pro-
tions of culture and its attributes, this is a relatively found impact on health and health care. In its summary
general definition, one that does not make clear the review of the literature about health and health care in
precise characteristics that allow a practitioner to say, the United States, the Institute of Medicine (Smedley
I am culturally competent. et al., 2003) found repeated examples of increased health
The dynamic nature of culture also makes it very risk for individuals from minority and disadvantaged
difficult to become and remain a culturally competent groups. Among disease differentials reported were
health-care provider without engaging in additional rates of diabetes, high blood pressure and its accompa-
efforts to remain current. It is, perhaps, more appro- nying sequelae, substance abuse, and some cancers.
priate to think of developing cultural competency as a Similarly, access to and outcomes of care are worse for
career-long and lifelong process. It is worth the time individuals from minority and socioeconomically dis-
and effort to be a culturally competent occupational advantaged communities. Such individuals received
therapist or occupational therapy assistant. Knowl- less effective pain management, fewer heart bypass
edge of and sensitivity to culture and socioeconomic procedures, fewer organ transplants, and more frequent
status are essential to the success of the occupational limb amputations. All of these have consequences for
therapy process in prevention and health promotion as subsequent occupational health, including employ-
well as rehabilitation. Furthermore, it is an expecta- ment, leisure activities, and ability to manage indepen-
tion supported by the professions core values and dent living.
attitudes (AOTA, 1993), the Code of Ethics (AOTA, While these data are sobering, it is important to avoid
2005), and Nondiscrimination and Inclusion Regard- a deficit model of culture and socioeconomic status.
ing Members of the Occupational Therapy Community Therapists sometimes assume deficits where none exist
(AOTA, 2004). or inaccurately expect clients from lower socioeconomic
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102 SECTION I Foundations and Key Concepts

circumstances to be less capable or more impaired than One of the cultural values imposed in their childhood
those from higher socioeconomic situations (Gajdosik & experiences was the importance of adhering to tradition.
Campbell, 1991; von Zuben, Crist, & Mayberry, 1991). Thus, preventive interventions would require recognizing
Given the tendency to focus on health disparities, it the challenge to traditional patterns of behavior and par-
is important to recognize that culture often enhances ents needs for information about managing childcare
aspects of function, health, and life satisfaction. and disciplinary tasks in the context of cultural beliefs.
As one example, in African American communities, It is important to note that increasingly, the clients
families feel a strong sense of obligation to care for for occupational therapy services are communities, not
their elderly family members (Pickett-Schenk, 2002). just individuals or small groups. Occupational therapists
That care is reinforced through strong affiliation with may assist in enhancing environmental characteristics
churches, which serve as community centers, and, to of a neighborhood or providing community-focused
some extent, social service agencies. The same is true educational interventions to enhance occupational per-
for the influences of socioeconomic status. It is not formance. In these situations, too, understanding of the
always the case that more money equals happiness or culture and socioeconomic characteristics of the com-
enhanced occupational satisfaction. Several years ago, munity can be important to framing interventions and
the author had a conversation with an elderly African ensuring successful outcomes. Community ownership
American woman living in government-subsidized of programs is vital to such intervention efforts (Baker
housing. After a lifetime as a housekeeper, she reported & Brownson, 1998; Bracht et al., 1994).
taking great pleasure in the steady (although tiny) In examining the lives and occupational patterns of
income she received from Social Security and the oppor- their clients, occupational therapists and occupational
tunity to do just what she wanted to do. therapy assistants must be aware of the interaction of
biological, personality, cultural, and socioeconomic
status. This complex interaction means that simply
Cultural and Socioeconomic learning facts about cultures is not sufficient to ensure
culturally sensitive care. Occupational therapy practi-
Factors and Occupation tioners must recognize the ways in which culture and
Human behavior reflects a complex interaction of cul- socioeconomic status affect lives and behaviors, and
tural, socioeconomic, biological, and environmental the ways in which individual characteristics and expe-
circumstances. In many situations, this interaction is riences interact with culture, either to support or inhibit
difficult to untangle. Yet the impact of this maze of satisfactory accomplishment of occupations.
factors has significant implications for engagement in
occupation and for occupational therapy interventions. Lifestyle
An example is the emerging dilemma of Mayan fami- Lifestyle choices are strongly influenced by cultural
lies (Burns, 1993). Individuals of Mayan background values and beliefs. Culture and socioeconomic factors
tend to be of very slight stature. As a result of modest im- affect, among many other decisions, whether or not to
provements in socioeconomic status, pregnant women marry, how to raise children, vocational plans, atti-
and young children have had access to improved diets. tudes and behaviors toward family members and the
Many Mayan children now tower over their parents. community, and engagement in religious and spiritual
Mayan women often carry their infants in fabric slings on activities. Examples abound in the global news. In
their backs; infants are now so much larger than a gener- Afghanistan under the Taliban, womens roles were
ation ago that it is exceedingly difficult for mothers to circumscribed such that they were not permitted to
continue this for as long as was previously the case. Tod- work or to be in public places unless entirely covered
dlers have become so large that their petite parents have by a burka. The removal of the Taliban government
difficulty lifting, carrying, bathing, and dressing them. In from power meant that the laws restricting womens
Mayan culture, respect for elders has been a central fac- behaviors were liberalized; cultural expectations have
tor for generations. Now that Mayan children are taller lagged somewhat, such that many women still choose
than their parents, discipline is more difficult and respect (for a variety of reasons) to appear in public only when
for elders less accepted. Thus a socioeconomic change clothed in a burka. This is an extreme example of cul-
altered a biological characteristic with significant conse- tural influence on behavior.
quences for culture and for occupational performance. There are less dramatic examples in cultural groups
An occupational therapist working with parents in this within the United States, often defined by religious
situation would have to help them find new ways to man- affiliation. For instance, certain groups or communities
age childcare and impose discipline. However, many believe that women should remain in the home to raise
Mayan mothers were raised in traditional circumstances. their children, should not use birth control, and should
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Chapter 5 Cultural and Sociological Considerations in Health Promotion 103

dress in modest clothing. While not carrying force of It is important to recognize that everyone has an
law, these groups cultural expectations hold consider- explanatory model for illness and that Western medicine
able power in influencing womens lifestyle choices. In does not possess all the answers to ensuring good
Amish communities, failure to behave as prescribed by health. Think about your own beliefs about illness. Did
community rules can lead to shunning by everyone in your mother teach you that going outside with wet hair
the community (Nolt, 1992). Fear of such punishment can cause a cold? Science has disproved this, but you
is a powerful incentive to behave in culturally appropri- may still be hesitant to go out with wet hair. In addition,
ate ways. there is evidence that expectations about treatment have
a powerful effect on its outcome. Consider the impact of
Construction of Illness/Disability placebo surgery to treat knee problems (Bernstein
Culture also influences beliefs about health, illness, & Quach, 2003), which was found to be as effective as
and disability. Kleinman, Eisenberg, and Goode (1978) real surgery in leading to reductions in knee pain and
indicated that individuals and groups have explanatory improvement in function.
modelsthat is, culturally mediated constructions of Culturally mediated explanatory models influence
what constitutes health, what causes illness, and what health-related behaviors just as they do behaviors in
would lead to cure. Western health care promotes a other spheres of life. Beliefs about effective treatment
biological explanatory model that holds that health is may affect choices about seeking care. In many cul-
the absence of disease, that disease is caused largely by tures, herbal remedies and traditional healers are per-
microorganisms, and that pharmaceutical medicines ceived as the first line of intervention for illness. Only
can cure disease. It does not consider the role of opti- when those are unsuccessful will some individuals seek
mism, spirituality, and other personal characteristics care by Western practitioners. Thus, a Chinese woman
that have been shown to contribute to wellness and might first turn to the local herbalist, then to an
healing. Compare this to the hot-cold explanatory acupuncturist, and only then to a Western physician.
model prevalent in many Hispanic cultures (Loue, Socioeconomic status affects choices about health
1998) that suggests that health is the presence of an care as well. Individuals living in impoverished cir-
appropriate balance of hot and cold influences on the cumstances may be unable to afford visits to physicians
body, that hot and cold can be defined for various sub- or the medications prescribed. They may be compelled
stances and occurrences, and that health can be to wait until a health condition has become an emer-
regained by restoring balance. In this system, someone gency before seeking care. Preventive interventions
with abdominal distress might be encouraged to eat or might be cheaper for society as a whole, but for indi-
drink substances defined as either hot or cold. Note that viduals without financial resources, these interventions
in this system, the labeling of substances as hot or cold might be impossible. Even advice about diet must be
is not based on the temperature but on some other tempered by the realities of poverty. Some poor neigh-
aspect of the substance. So in one encounter in borhoods do not have grocery stores with fresh pro-
Guatemala, cortisone cream (a modern and unfamiliar duce. Residents who are too poor to own and maintain
substance) was labeled as hot when individuals using it cars for easy transportation may be forced to purchase
were advised to stay out of the sun (Love, 1998). whatever food is available at the local convenience
Explanatory models also reflect beliefs about indi- store, typically at prices higher than in surrounding
vidual control over disease. Depending on cultural affluent neighborhoods.
norms, individuals may feel that they can control their
circumstances, a belief labeled internal locus of con- Culture and Occupation
trol, or they may feel that they are subject to uncontrol-
lable external factors, a belief known as external locus As has already been noted, culture and socioeconomic
of control. So in some Hispanic cultures, individuals status affect lifestyle choices. A significant characteristic
believe that illness is the will of God and must there- of lifestyle is an individuals constellation of occupational
fore be cured by God rather than by taking medicine. choices. The Framework (AOTA, 2008) notes that occu-
Chinese individuals may believe that the patients role pational choice is predicated on the contexts (including
is passive and dependent (Jang, 1995). Occupational culture) in which activities occur, the demands of the
therapy tends toward emphasis on individual control. activity, and the characteristics of the individual. All these
This belief can lead to conflict and poor outcomes factors affect occupation in all areas, including activities
when the client is more inclined toward external locus of daily living (ADLs), instrumental activities of daily
of control. It may also understate the effects of real living (IADLs), education, work, play, leisure, and social
external forces, such as public policy and environmen- participation. Further, culture and socioeconomic status
tal constraints. influence performance patterns and performance skills.
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104 SECTION I Foundations and Key Concepts

Activity Demands afford skin care and grooming products, expectations

Demands of activities are mediated by socioeconomic about appropriate dress, access to particular food ingre-
and cultural variables. In some rural, impoverished dients, complexity of finances and perceptions about
communities (e.g., in rural Appalachia), the process of gender roles in managing money are all examples of
acquiring an education might be constructed to mean the ways in which self-care can differ among groups.
attending public school until age 16, when law permits Likewise, in making work choices, access to education
withdrawal. In a middle-class suburban neighborhood, and transportation, gender roles, and other culturally
education might mean completion of an undergraduate and socioeconomically mediated factors have substan-
college degree in a state-funded college or university. tial influence. In an excellent summary of the chal-
In an affluent suburban neighborhood, education might lenges facing young people in impoverished inner-city
mean undergraduate and graduate degrees from high- neighborhoods as they attempt to find work and move
status universities. up the social ladder, Newman and Newman (1999)
describes the ways in which cultural expectations can
Context and Client Factors become an added impediment. The young people she
Context for activity includes the physical and social describes lack role models who had successful careers
environment. The physical environment is shaped to by majority U.S. cultural standards. They battled
some extent by nature but also by humans with partic- expectations of the majority culture that they were lazy
ular cultural values and socioeconomic resources. So, and unmotivated. Such influences affect all areas,
for example, a culture in which communal activities are including play, leisure, and social participation.
highly valued would probably build homes conducive An often-overlooked performance area is religious
to easy access and in close proximity to one another. In observance. There is considerable evidence that for
an individualistic culture, homes might be more widely some racial or ethnic groups, religion is a central focus
spaced, perhaps with gated access. These choices about of life and activities (cf., Swanson, Crowther, Green,
home construction are culturally mediated and then & Armstrong, 2004). Participation in religious cere-
affect a variety of interactions in the community there- monies, attendance at worship services, and other
after. One elderly grandmother with whom the author is religious activities can provide meaning to life and
acquainted blamed the rise in youth crime to the motivation in other areas. For some individuals, every
demise of the front porch. She believed that when fam- area incorporates a religious element, so ADLs (dress
ily outdoor activity turned to the backyard, neighbor- in particular), work, and leisure choices all reflect reli-
hoods lost a natural source of neighborhood watch. gious influence.
Characteristics of the individual (client factors) inter-
act with cultural and socioeconomic factors (context) to Performance Patterns
lead to unique occupational choices. For example, in The influence of culture and socioeconomic status on
almost every culture, gender-appropriate roles are cul- performance patterns has been well documented. In
turally defined. And yet, even when those roles are quite the movie Bowling for Columbine, Michael Moore
rigid, the personal characteristics of the individual (2002) movingly demonstrated how working individ-
woman will affect the way in which occupations are uals in impoverished neighborhoods routinely trav-
selected and enacted. Under the Taliban, some women eled several hours each way by public transportation
in Afghanistan continued to find ways to acquire an to get their children to day care and then to their
education and to work at vocations they valued, such as minimum-wage jobs in the suburbs. This kind of pat-
health care or teaching, in spite of the possible dire tern is imposed by both cultural (segregation) and
consequences should their activities be discovered. In socioeconomic (inadequate funds to purchase and
the United States, women whose cultures promote their maintain a car) factors.
role as homemakers and mothers may establish small
businesses selling products at house parties or may Performance Skills
demonstrate their leadership and organizational skills in The interaction of culture, socioeconomic status, and
their childrens school organizations or in community performance skills is perhaps more surprising. Perfor-
volunteer settings. mance skills and motor, process, and communication
skills are largely characteristics of the individual. Motor
Areas of Occupation and process skills are mediated largely by the central
Activities of daily living (ADLs) are an example of nervous system and might, therefore, be considered to be
performance areas of occupation that are clearly influ- more individual than cultural or socioeconomic factors.
enced by cultural and socioeconomic factors. Ability to Yet children living in poverty have high rates of lead
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Chapter 5 Cultural and Sociological Considerations in Health Promotion 105

poisoning, which causes neurological damage (Canfield Are there traditional customs that influence com-
et al., 2003). Consequently, such children might have munity members choices about interacting with
impairments in both motor and process skills. There is Western health care?
also evidence that culture affects neurological develop- What are the individuals beliefs about education,
ment. Chinese individuals, whose written language is work, and appropriate leisure activities?
pictographic, perceive stimuli in the environment more Does the cultural background of the individual or
globally than individuals from Western countries (Yoon, community include a spiritual or religious compo-
Hasher, Feinberg, Rahhal, & Winocur, 2000). This is nent that must be considered in promoting wellness?
believed to be a consequence of brain plasticity leading The answers to these questions are all dependent on
to differential development in the presence of differential particular cultural influences. The beliefs of an individ-
environmental stimuli. ual in an inner-city Puerto Rican neighborhood will
differ greatly from those of a more acculturated Mexican
American individual. African Americans whose families
Occupational Therapy have lived in the United States for many generations will
in the Promotion of Health be quite different from recent Somali refugees.
Unless the appropriate information is obtained dur-
and Wellness: Cultural and ing evaluation, intervention options cannot be appro-
Socioeconomic Considerations priately identified. The emphasis on client-centered
intervention in occupational therapy (AOTA, 2008) is
The goal of prevention in occupational therapy is
not possible unless the clients strengths, needs, and
avoidance of dysfunction in occupations that clients
self-identified goals are well understood.
need and want to accomplish. In the case of prevention
Given the complexity of the individual, cultural,
and wellness, the key question is: How can occupations
and socioeconomic factors that affect occupation and
of individuals and communities best be supported to
occupational choice, how can occupational therapists
avoid dysfunction and promote wellness? As with other
ensure that they gather the right information and apply
forms of occupational therapy intervention, the process
it correctly to intervention? It is impossible to know
involves evaluation, intervention, and examination of
everything about particular cultures and to determine
outcomes (AOTA, 2008).
all the members of that group, and even if it were
At each step of the process, cultural and socioeco-
possible, individual characteristics and experiences
nomic factors must be addressed. In evaluation, consid-
would lead each person to express cultural values and
eration must be given to the kinds of instruments used
beliefs differently.
and their applicability to individuals from various cul-
Perhaps the most helpful strategy is an inquiry-
tural or socioeconomic groups. Too often, standardized
based approach to evaluation (Bonder et al., 2002).
instruments ignore culture, giving an inaccurate picture
An inquiry-based approach uses ethnographic princi-
of the strengths, needs, and goals of the individual (Paul,
ples that encourage respectful questioning and careful
1995). Likewise, economic resources are often over-
observation. While it is helpful to have a fund of cul-
looked. Among the relevant issues that are culturally
tural knowledge that might guide initial and follow-up
or economically mediated, therapists should consider
questions, genuine understanding of the individual
the following:
must be based on that persons responses rather than on
What language is spoken? stereotypical descriptions of cultural groups.
How is information conveyed and shared? Such thoughtful questioning and interpretation can
What beliefs does the client hold about health yield significant benefits. As an example, one local
and wellbeing? What do these constructs mean to chapter of the Alzheimers Association developed sup-
him or her? port groups as a way to prevent excessive stress, and
In what ways are daily activities affected by thereby illness, among family caregivers. However, as
cultural or economic circumstances? the service was instituted, staff noted that the majority
What is the nature of family and neighborhood of the families using its services were white, although
interaction in the community? the chapter was located near a large African American
What is the persons gender role and age-related community. After puzzling over this for a while, one
expectations? staff member read about African American culture
Who makes decisions for the person? A family and found that churches were described as central to
elder? The male leader of the family? The community life (Swanson et al., 2004). Based on this
individual? fact, the staff person went to talk with the minister at
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106 SECTION I Foundations and Key Concepts

one of the African American churches. It quickly Finally, DeMars (1992) describes a community health
became apparent that the church was indeed a commu- promotion intervention for Native American children
nity center for that African American community, and and adults in Canada. The program focused on preserv-
the minister was an important opinion leader. The staff ing the participants ethnic heritage. Participant feed-
spent time getting to know him and, through him, other back led to modifications of the program, which was
community leaders. These conversations made clear to perceived as helpful in promoting wellness and life skills.
the staff that both the nature of the programs and the
outreach strategies had to be changed for these commu-
nities. When the Alzheimers Association support Conclusion
groups were moved to church meeting rooms and Effective occupational therapy intervention requires an
members of church leadership were present for the first understanding of the clients needs and wishes. Those
several meetings, residents of the community felt much needs and wishes are mediated by the clients personal
more comfortable about participating. In addition, the characteristics and by his or her cultural and socioeco-
minister announced the groups on Sundays. These nomic circumstances. As is true of personality and
modifications made a tremendous difference in the biological characteristics, the individuals cultural expe-
reception of the programs in that community. riences are highly idiosyncratic, even though culture is
As another example, thoughtful design of environ- a group phenomenon. Likewise, socioeconomic factors
ments can support cultural values and thereby provide are interpreted differently by individuals. Thus, recom-
tremendous benefits in preventing occupational dys- mendations to incorporate cultural and socioeconomic
function. In communities where child-raising is per- factors into evaluation and intervention require com-
ceived as a community function, with close interaction plex skills on the part of the therapist. Acquisition of
among neighbors and family members, high-rise these skills is an ongoing process. Professionals who
apartments with little green space can serve as a bar- make the effort to understand their clients in the con-
rier to effective childcare. The resulting isolation can text of their cultural and socioeconomic situations
lead to depression for parents robbed of support net- are likely to find both the process and outcomes of
works and grandparents deprived of regular contact intervention to be greatly improved.
with grandchildren. Children lose opportunities for Culture and socioeconomic status are realities of life
support from an array of adults and valuable opportu- and have significant impact on access to occupations,
nities to observe role models. Adding communal areas occupational preferences, and enactment of occupations.
can support traditional values about childrearing and Thus, they are important factors in developing effective
reduce parental stress. occupational therapy interventions. Occupational therapy
Several health promotion programs that incorporate professionals can draw upon the strengths conferred by
cultural elements or the social context are described cultural values and beliefs and can prevent occupational
in the occupational literature. Rebeiro and colleagues dysfunction by incorporating those values and beliefs in
(2001) describe the Northern Initiative for Social Action the intervention process. Townsend and Wilcock empha-
(NISA), a consumer-run, occupation-based organiza- size this point: Humans are occupational beings. Their
tion located in northeastern Ontario, Canada. Its goal is existence depends on enablement of diverse opportunities
to promote participation in personally meaningful and and resources for participation in culturally-defined and
socially valued occupations for individuals with mental health-building occupations (Townsend & Wilcock,
illness living in the community. Thus, it is a tertiary pre- 2004, p. 76).
vention program, designed to prevent relapse and to
encourage continuing health for individuals already
diagnosed with a disorder. Qualitative measures of out-
come suggest that the program met participants needs
For Discussion and Review
for belonging. 1. How would you describe your own cultural
Another example described by Frank and colleagues influences? In what ways do they differ from your
(2001) is a program called New Stories/New Cultures. parents?
This is an activity-based, after-school enrichment pro- 2. What beliefs and values have you been taught as
gram for students in low-income neighborhoods with you learn to become an occupational therapist?
large populations of African American and Hispanic 3. In what ways do you think your classmates and
American residents. The students were more likely to instructors share your values and beliefs? In what
feel they were building skills when they were engaged in ways do you think they differ? How could you find
activities that were challenging and enjoyable. They out if your perceptions of their values and beliefs
term their approach a direct cultural intervention. are accurate?
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Chapter 5 Cultural and Sociological Considerations in Health Promotion 107

4. Reflecting on your experiences so far in working (2d ed.). American Journal of Occupational Therapy,
with clients or patients, what incidents have you 62, 62583.
seen in which you thought culture or socioeco- Arnason, E., Sigurgislason, H., & Benedikz, E. (2000). Genetic
nomic status were factors? How did you or the homogeneity of Icelanders: Fact or fiction? Nature Genetics,
25, 37374.
therapist address them? What might you or the
Association of Professional Chaplains, Association for Clinical
therapist have done differently? Pastoral Education, Canadian Association for Pastoral Prac-
5. Have you ever been misunderstood because of cul- tice and Education, National Association of Catholic Chap-
tural or socioeconomic differences? What do you lains, and National Association of Jewish Chaplains. (2001).
wish you or those with whom you were interacting A white paper. Professional chaplaincy: Its role and impor-
might have done differently? tance in healthcare. Journal of Pastoral Care, 55, 8197.
Baker, E. A., & Brownson, C. A. (1998). Defining characteristics
of community-based health promotion programs. Journal of
Research Questions Public Health Management and Practice, 4(2), 19.
Baptiste, S. (1988). Murial Driver Memorial Lecture: Chronic
Research related to occupational therapy interventions pain, activity, and culture. Canadian Journal of Occupational
that appropriately incorporate cultural and socioeco- Therapy, 55, 17984.
nomic factors in prevention and health promotion is Barney, K. F. (1991). From Ellis Island to assisted living:
Meeting the needs of older adults from diverse cultures.
sparse, with many questions yet to be answered. American Journal of Occupational Therapy, 45, 58693.
1. Describe the occupational beliefs, patterns, and barri- Beauregard, C., & Solomon, P. (2005). Understanding the
ers to participation for various communities (cf., Lau, experience of HIV/AIDS for women: Implications for occu-
Chi, & McKenna, 1998; Piskur, Kinebanian, & pational therapists. Canadian Journal of Occupational
Josephsson, 2002). Therapy, 72, 11320.
2. Identify effective research strategies for evaluating Belcham, C. (2004). Spirituality in occupational therapy:
the success of culturally sensitive prevention efforts. Theory in practice? British Journal of Occupational
Therapy, 67(1), 3946.
3. Describe intervention strategies for working with
Bernstein, J., & Quach, T. (2003). Questioning the value of
individuals from various cultural backgrounds. arthroscopic knee surgery for osteoarthritis. Cleveland
4. Examine outcomes of intervention strategies in Clinic Journal of Medicine, 70, 40107.
terms of increased self-esteem, increased participa- Bonder, B. R., Martin, L., & Miracle, A. (2002). Culture in
tion, reduced disability, and other important health clinical care. Thorofare, NJ: SLACK.
and wellness outcomes. Bonder, B. R., Martin, L., & Miracle, A. (2004). Culture
5. Swanson and colleagues (2004) suggest that in emergent in occupation. American Journal of Occupational
African American communities, churches can play Therapy, 58, 15968.
a major role in providing health information and Bowman, O. J., & Wallace, B. A. (1990). The effects of socioe-
encouraging healthy behaviors. Among the many conomic status on hand size and strength, vestibular function,
research questions they pose is: What models best visuomotor integration, and praxis in preschool children.
American Journal of Occupational Therapy, 44, 61021.
describe the role of religious organizations in
Bracht, N., Finnegan, J. R., Rissel, C., Weisbrod, R., Gleason, J.,
promoting healthy communities? Corbett, J., & Veblen-Mortenson, S. (1994). Community
ownership and program continuation following a health
demonstration project. Health Education Research, 9,
References 24355.
Burns, A. F. (1993). Maya in exile: Guatemalans in Florida.
Philadelphia: Temple University Press.
Alvord, L. A., & Van Pelt, E. C. (1999). The scalpel and the
silver bear. New York: Bantam Books. Canadian Association of Occupational Therapists (1997; 2002).
Enabling occupation: An occupational therapy perspective
American Occupational Therapy Association. (1993). Core val- (Rev. ed.). Ottawa, ON: CAOT Publications ACE.
ues statement and attitudes of occupational therapy practice.
American Journal of Occupational Therapy, 47, 108586. Canfield, R. L., Henderson, C. R., Cory Slechta, D. A., Cox,
C., Jusko, T. A., & Lanphear, B. P. (2003). Intellectual im-
American Occupational Therapy Association. (2004). Occupa- pairment in children with blood lead concentrations below
tional therapys commitment to nondiscrimination and inclu- 10g per deciliter. New England Journal of Medicine, 348,
sion. American Journal of Occupational Therapy, 58, 668. 151726.
American Occupational Therapy Association. (2005). Occupa- Christiansen, C., & Baum, C. (1997). Person-environment oc-
tional therapy code of ethics. American Journal of Occupa- cupational performance: A conceptual model for practice.
tional Therapy, 59(6), 63942. In C. Christiansen & C. Baum (Eds.), Occupational ther-
American Occupational Therapy Association. (2008). Occupa- apy: Enabling function and well-being (2d ed., pp. 4770).
tional therapy practice framework: Domain and process Thorofare, NJ: SLACK.
1193_Ch05_096-109.qxd 6/8/09 6:50 PM Page 108

108 SECTION I Foundations and Key Concepts

Collins, J. S., Paul, S., & West-Frasier, J. (2001). The utiliza- Lau, A., Chi, I., & McKenna, K. (1998). Self-perceived quality
tion of spirituality in occupational therapy: Beliefs, prac- of life of Chinese elderly people in Hong Kong. Occupa-
tices, and perceived barriers. Occupational Therapy in tional Therapy International, 5, 11839.
Health Care, 14(3/4), 7392. Levine, R. E. (1984). The cultural aspects of home care delivery.
DeMars, P. A. (1992). An occupational therapy life skills American Journal of Occupational Therapy, 38, 73438.
curriculum model for a Native American tribe: A health Loue, S. (Ed.). (1998). Handbook of immigrant health. New
promotion program based on ethnographic field research. York: Plenum Press.
American Journal of Occupational Therapy, 46, 72736.
Mayers, C. A. (2004). Towards understanding spirituality.
Dillard, M., Andonian, L., Flores, O., Lai, L., MacRae, A., & British Journal of Occupational Therapy, 67, 191.
Shakir, M. (1992). Culturally competent occupational
therapy in a diversely populated mental health setting. McColl, M. A. (2003). Spirituality and occupational therapy.
American Journal of Occupational Therapy, 46, 72126. Ottawa, ON: Canadian Association of Occupational
Therapists Publications, ACE.
Dunton, W. R. (1915). Occupational therapy: A manual for
nurses. Philadelphia: Saunders. Mills, C. W. (1958/2005). The structure of power in American
society. In T. M. Shapiro (Ed.), Great divides: Readings in
Fadiman, A. (1997). The spirit catches you and you fall down. social inequality in the United States (3d ed., pp. 13946).
New York: Noonday Press. New York: McGraw-Hill.
Fitzgerald, M. H., Mullavey-OByrne, C., & Clemson, L. (1997). Moore, M. (Writer/Director). (2002). Bowling for Columbine
Cultural issues from practice. Australian Journal of Occu- [Motion picture]. United States: Metro-Goldwyn-Mayer.
pational Therapy, 44, 121.
National Research Council. (1997). Racial and ethnic differ-
Frank, G., Fishman, M., Crowley, C., Blair, B., Murphy, S. T., ences in the health of older Americans. Washington,
Montoya, J. A., Hickey, M. P., Brancaccio, M. V., & DC: Author.
Bensimon, E. M. (2001). The new stories/new cultures after-
school enrichment program: A direct cultural intervention. Newman, B. M., & Newman, P. R. (1999). Development
American Journal of Occupational Therapy, 55, 50108. through life: A psychosocial approach (7th ed.). Belmont,
CA: Wadsworth.
Frey, B. B., Daaleman, T. P., & Peyton, V. (2005). Measuring
a dimension of spirituality for health research: Validity of Nolt, S. M. (1992). A history of the Amish. Intercourse, PA:
the Spirituality Index of Well-Being. Research on Aging, Good Books.
27, 55677. Paul, S. (1995). Culture and its influence on occupational
Gajdosik, C. G., & Campbell, S. (1991). Effects of weekly therapy evaluation. Canadian Journal of Occupational
review, socioeconomic status, and maternal belief on moth- Therapy, 62, 15461.
ers compliance with their disabled childrens home exer- Phillips, I. (2003). Infusing spirituality into geriatric health
cise program. Physical and Occupational Therapy in care: Practical applications from the literature. Topics in
Pediatrics, 11(2), 4765. Geriatric Rehabilitation, 19, 24956.
Hakansson, C., Svartivk, L., Lidfeldt, J., Nerbrand, C., Samsioe, Pickett-Schenk, S. A. (2002). Church-based support groups for
G., Schersten, B., & Nilsson, P. M. (2003). Self-rated health African-American families coping with mental illness:
in middle-aged women: Associations with sense of coher- Outreach and outcomes. Psychiatric Rehabilitation Journal,
ence and socioeconomic and health-related factors. Scandi- 26, 17386.
navian Journal of Occupational Therapy, 10, 99106. Piskur, B., Kinebanian, A., & Josephsson, S. (2002). Occupa-
hyperdictionary. (2005a). Religion. Retrieved January 6, 2005, tion and well-being: A study of some Slovenian peoples
from http://www.hyperdictionary.com/dictionary/religion. experiences of engagement in occupation in relation to
hyperdictionary. (2005b). Spirituality. Retrieved January 6, 2005, well-being. Scandinavian Journal of Occupational Therapy,
from http://www.hyperdictionary.com/dictionary/spirituality. 9(2), 6370.
Iwama, M. K. (2004). Revisiting culture in occupational therapy: Rebeiro, K. L., Day, D. G., Semeniuk, B., OBrien, M. C., &
A meaningful endeavor. OTJR: Occupation, Participation, Wilson, B. (2001). Northern Initiative for Social Action:
and Health, 24, 23. An occupation-based mental health program. American
Journal of Occupational Therapy, 55, 493500.
Jang, Y. (1995). Chinese culture and occupational therapy.
British Journal of Occupational Therapy, 58, 10306. Rippentrop, A. E., (2005). A review of the role of religion and
spirituality in chronic pain populations. Rehabilitation
Kleinman, A. M., Eisenberg, L., & Good, B. (1978). Culture, Psychology, 50, 27884.
illness, and care. Annals of Internal Medicine, 88, 25158.
Rivera-Mosquera, E. T. (2005). Differential predictors of
Krieger, N., Williams, D. R., & Moss, N. E. (1997). Measuring substance abuse outcome in African American and
social class in U.S. public health research: Concepts, white populations (Ohio). Dissertation Abstracts Interna-
methodologies, and guidelines. Annual Review of Public tional: Section B: The Sciences and Engineering,
Health, 18, 34178. 65(8-B), 3169.
Krusen, N. (2003, June 5). The occupational adaptation Sacks, O. (1989). Seeing voices: A journey into the world of
process during the transition from student to practitioner, the deaf. Berkeley: University of California Press.
presented at AOTA Institute 05, Exploring Adaptation:
An Occupational, Contextual, and Intrapersonal Process in Schulz, E. K. (2004). Spirituality and disability: An analysis
Occupational Therapy, Texas Womens University. of select themes. Occupational Therapy in Health Care,
18(4), 5783.
Kuper, A. (1999). Culture: The anthropologists account.
Cambridge, MA: Harvard University Press.
1193_Ch05_096-109.qxd 6/8/09 6:50 PM Page 109

Chapter 5 Cultural and Sociological Considerations in Health Promotion 109

Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.) (2003). U.S. Department of Commerce. (1999). The emerging minority
Unequal treatment: Confronting racial and ethnic dispari- marketplace. Washington, DC: Author.
ties in health care. Washington, DC: Institute of Medicine. U.S. Department of Health and Human Services, Office of the
Swanson, L., Crowther, M., Green, L., & Armstrong, T. (2004). Secretary. (2000). National standards on culturally and lin-
African Americans, faith and health disparities. African guistically appropriate services (CLAS) in health care. Fed-
American Research Perspectives, 10(1), 7988. eral Register, 65(247), 8086580879.
Tedlock, D., & Mannheim, B. (1995). Introduction. In D. Tedlock von Zuben, M. V., Crist, P. A., & Mayberry, W. (1991). A pilot
& B. Mannheim (Eds.), The dialogic emergence of culture study of differences in play behavior between children of
(pp. 132). Urbana, IL: University of Illinois Press. low and middle socioeconomic status. American Journal
Townsend, E. (1997). Inclusiveness: A community dimension of Occupational Therapy, 45, 11318.
of spirituality. Canadian Journal of Occupational Therapy, Wang, V. O., & Sue, S. (2005). In the eye of the storm: Race
64, 14655. and genomics in research and practice. American
Townsend, E., De Laat, D., Egan, M., Thibeault, R., & Wright, Psychologist, 60, 3745.
W. A. (1999). Spirituality in enabling occupation: A Wicasa, W. (2005). Explanation of star quilt. Retrieved March
learner-centered workbook. Ottawa, ON: Canadian 16, 2005, from http://www.bluecloud.org/18.html.
Association of Occupational Therapists Publications, ACE. Wilding, C., May, E., & Muir-Cochrane, E. (2005). Experi-
Townsend, E., & Wilcock, A. A. (2004). Occupational justice ence of spirituality, mental illness and occupation: A life-
and client-centered practice: A dialogue in progress. sustaining phenomenon. Australian Occupational Therapy
Canadian Journal of Occupational Therapy, 71(2), 7586. Journal, 52, 29.
Udell, L., & Chandler, C. (2000). The role of the occupational Yoon, C., Hasher, L., Feinberg, F., Rahhal, T. A., & Winocur, G.
therapist in addressing the spiritual needs of clients. British (2000). Cross-cultural differences in memory: The role of
Journal of Occupational Therapy, 63, 48994. culture-based stereotypes about aging. Psychology of
U.S. Census Bureau. (2000). 2000 Census of Population, Pub- Aging, 15, 694704.
lic Law 94-171 Redistricting Data File. Retrieved January
6, 2005, from http://factfinder.census.gov.
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Chapter 6

Population Health:
An Occupational Rationale
Ann A. Wilcock

A human being is part of the whole, called by us Universe, a part limited in time and
space. He experiences himself, his thoughts and feelings as something separated from
the resta kind of optical delusion of his consciousness. This delusion is a kind of
prison for us, restricting us to our personal desires and to affection for a few persons
nearest to us. Our task must be to free ourselves from this prison by widening our circle
of compassion to embrace all living creatures and the whole of nature in its beauty.
Albert Einstein

Learning Objectives
This chapter is designed to enable the reader to:
Articulate basic concepts of population health. Discuss the potential role of occupational therapy
Discuss the relationship between health and in population health.
occupation. Describe how occupational science can inform
Identify occupational determinants of health. population health interventions.
Describe five approaches to population health.

K e y Te r m s
Community Ecological sustainability Occupation Preventive medicine
Community Health Occupational justice Social epidemiology
development Health promotion Population health Wellness approach
Ecological public health

Introduction Occupational deprivation, alienation, and imbalance

could and should also be a focus of occupational ther-
In this chapter, the rationale for taking an occupational apy research and intervention. This assertion will be
approach to population health will be considered. Tak- justified using the framework of occupational science
ing this approach is an important task for occupational and population health with reference to their impact on,
therapy assistants and occupational therapists because or potential affiliation with, occupational therapy. The
of a close association between what people do and their exploration is begun by defining both occupation and
health status. To get some idea of the scope of the work population health in current terms and clarifying how
that needs to be done in this regard, the fundamental an occupation perspective might fit within, or extend
relationship between positive or negative health and the concept of, population health.
what people do or are unable to do will be examined.
This will lead to tracing the possible effects of underly-
ing occupational determinants on health. This will An Occupational Perspective
highlight not only the evidence of the benefits of occu-
pation that support occupational therapys potential
of Population Health
contribution to population health, but also the negative Many authors have defined occupation in different
consequences of occupational deprivation, alienation, ways. As it is used in this chapter, occupation is seen
and imbalance. as central to the human experience in that it comprises
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Chapter 6 Population Health: An Occupational Rationale 111

all that people do in order to fulfill basic needs and of a level of health that will permit them to lead a
meet social and environmental challenges across socially and economically productive life (WHO, 1984),
the sleepwake continuum. It can be economically, thereby linking occupation as an outcome of health sta-
socially, or politically driven, and it can be obligatory tus. Other WHO documents demonstrate appreciation
or self-chosen to meet individual needs, pleasures, and of causal and outcome links between occupation and
purposes. It draws on and develops peoples potential health