An occupational perspective of childhood poverty.
While living in poverty is known to have important health consequences for children, its impact on their occupations is not as well understood. This article brings together international and New Zealand (NZ) national policy documents and evidence from research to examine the effect of poverty on children's occupations and the potential contribution of occupational therapists to this important public health issue. Child poverty can be framed as occupationally unjust and can lead to occupational deprivation for these children. The authors suggest that occupational therapists, with their belief in achieving equitable health outcomes through meaningful occupation, can work in a transdisciplinary way to help children living in a state of poverty.
Occupational therapy, poverty, children, public health, social determinants of health.
Leadley, S., & Hocking, C. (2017). An occupational perspective of childhood poverty. New Zealand Journal of Occupational Therapy, 64(1), 23-31.
Just under a third of all children in Aotearoa New Zealand live in financial poverty (Child Poverty Action Group [CPAG], 2014). The profoundly negative effects of poverty on children's health is an important public health issue that has been well documented. What is less well understood is the impact of social factors such as poverty (i.e. relative poverty or low income) on children's occupations and the consequent impact on their prospects in life. Whilst the cause of poverty is multifaceted, and can be mediated by various factors (e.g. positive parenting and social support, education, employment) material poverty has been widely researched and is the focus of this article. The risks that children living in poverty face are exacerbated by the widening gap between the poor and the rich, especially in developed and wealthier countries (UNICEF Office of Research, 2014). There is broad agreement amongst those advocating on behalf of children that action needs to be taken urgently to address this growing inequality (World Health Organization, 2008). This article brings together international and national policy documents and evidence from research with the goal of examining occupational therapists' potential contribution to ameliorating the impact of child poverty. It proposes that occupational therapists, with their belief in achieving equitable health outcomes through meaningful occupation, can work in a transdisciplinary way to help children living in a state of poverty.
This review was conducted as part of a master's programme being completed at AUT by the lead author. Its aim was to better understand how social factors such as poverty effect children's occupations, rather than the mechanisms by which people fall into or progress out of poverty. An initial literature review was completed using keyword search terms such as occupational therapy, child poverty and New Zealand but also included a wider review of occupational therapy's role in public health and the broader issue of child poverty. Databases used included EBSCO and SCOPUS. A further review of references in articles reviewed, along with searches of relevant NZ websites (e.g. OTNZ-WNA, UNICEF, Child Commissioner, Child Poverty Action Group NZ), revealed further pertinent resources.
Poverty and health inequity
Socioeconomic deprivation, or poverty, is commonly defined as not being able to experience well-being over a range of life circumstances or a level of deprivation below what society deems acceptable (Gunasekara, Carter, Crampton, & Blakely, 2013). Relative poverty can be understood as the level of income or deprivation that falls below a threshold which society deems acceptable (Gunasekara et al., 2013). Experiencing poverty has been described as a "lack of freedom", a "crushing daily burden... and fear of what the future will bring" (The World Bank, n.d., para. 4). Qualitative research has shown that, for children, being poor does not only have a material impact on their lives, but it also has a profoundly social cost (Attree, 2006).
Being deprived of the basic necessities of life, such as adequate food, water, housing, education, or suitable clothing, results in higher rates of illness and mortality, with lower socioeconomic levels associated with worse health outcomes (Marmot, Friel, Bell, Houweling, & Taylor, 2008). These health outcomes begin before birth and continue during the early years of a child's life (Marmot & Bell, 2013). In addition to the direct threats to health, poverty destabilises children's daily life, threatens their safety, and creates stress for both the child and their parents or caregivers, thereby reducing their ability to cope with adversity (Rosenbaum & Johnson, 2013).
Social, rather than biological, determinants are among the most important explanations for how health inequity persists in society. Social determinants of health are the conditions "in which people are born, grow, live, work and age" (Marmot, Allen, Bell, Bloomer, & Goldblatt, 2012, p. 1012). The unequal distribution of income, resources and imbalances in power, such as for those living in poverty, are key factors in creating health inequities (Marmot et al., 2012).
Poverty and connection with community or neighbourhood
A significant amount of published literature demonstrates the relationship between living in a community with high levels of poverty and reduced health outcomes. For example living in substandard housing (e.g. lack of ventilation, inadequate insulation) and living with housing insecurity (e.g. overcrowding, high housing costs, unstable neighbourhoods, homelessness) all contribute to poor health (Baker, McDonald, Zhang, & Howden-Chapman, 2013). Children are especially vulnerable to environmental factors and poverty is a key factor in creating unsafe and unstable living conditions for children (Rosenbaum & Johnson, 2013). Furthermore, growing up in an impoverished neighbourhood is associated with long-term adverse health outcomes (Marmot & Bell, 2012).
Not all aspects of living in a neighbourhood with socioeconomic disadvantage are detrimental to health. For example, for people living in impoverished neighbourhoods there is often a greater need to walk and this has health benefits (Turrell, Haynes, Wilson, & Giles-Corti, 2013). Additionally, irrespective of deprivation levels, positive social capital, which refers to the "features of the social structure [that] facilitate the actions of individuals within that structure" (Kawachi, Takao, & Subramanian, 2013, p. 4), is a strong protective factor for a community or neighbourhood. Social capital can influence health outcomes at an individual or neighbourhood level (Kim, Subramanian, Gortmaker, & Kawachi, 2006), such as the resilience shown by a community when recovering after a natural disaster.
Poverty, human rights, and occupation
Every person has the right to enjoy good health (United Nations, 1948). However, as described earlier, the circumstances in which people are born and live are unequal and being poor is a significant factor that creates inequities in health (Marmot et al., 2012). Poverty and social deprivation is also known to lead to people's human rights being breeched and to social injustices (Brownlee, 2013; UNICEF NZ, 2013).
Occupation, meaning all the things people do in everyday life, has been framed as a fundamental human right. For example, restriction in the ability to engage in occupations that are meaningful for a person or community is a matter of occupational injustice (Wilcock & Townsend, 2014). A related concept, occupational deprivation, is defined as being prevented from doing necessary and meaningful occupations by external restrictions (Whiteford, 2000). There is an assumption, not yet backed by research findings, that people living in poverty are more likely than others to experience occupational deprivation (Townsend & Wilcock, 2004). However, the relationships of poverty, occupation and health are complex. For example, being too poor to own a car makes it more difficult to shop for healthy food, but might result in higher levels of active transport (e.g., walking) to access work, educational or leisure occupations (Dorling, 2013). What is required is further research that explores the nexus between social issues such as poverty and its impact on people's occupations.
Poverty and its effect on children's health, their rights, and occupations
To grow and thrive, children need the necessities of life (Rosenbaum & Johnson, 2013) and this includes engaging in daily activities such as school and play (Bazyk & Bazyk, 2009). These necessities are explicitly identified in the Convention on the Rights of a Child (United Nations, 1989) which asserts children's right to education, and to engage in leisure, play, artistic and cultural activities.
Children living in poverty experience greater levels of social exclusion (Attree, 2006), negative stereotyping and marginalization, with resultant restrictions on their opportunities for full participation in society (Te One, Blaikie, Egan-Bitran, & Henley, 2014). They have fewer opportunities to participate in leisure activities (Bazyk & Bazyk, 2009) and face restricted opportunities for physical activity (Cahill & Suarez-Balcazar, 2009). The consequent disruptions to cognitive, motor, social and emotional development negatively affect performance in occupations such as play, schooling, and social life (Lysack & Adamo, 2014). In turn, these hardships may negatively affect their occupational choices (Galvaan, 2012).
However, not all poor children will fare badly. For example a child may overcome situations of poverty and deprivation through his or her own capabilities, through caring and effective parenting, through increased educational attainment and upward socioeconomic movement of their parents, by growing up in social and cultural environments that are positive, or through positive social capital (Kawachi et al., 2013; Marmot & Bell, 2013; Wadsworth & Butterworth, 2005). As the voice of a young New Zealander makes clear, "Just cos people are poor doesn't mean they can't be strong. Support from your family and supporting families helps" (Children's Commissioner, 2012, p. 22). However, living with persistent poverty does place children and families at increased risk of harm and is socially unjust.
Nonetheless, what is lacking in the discourse about child poverty, notwithstanding the documented evidence about the effects of poverty on children's health, is an occupational perspective. For example, taking an occupational perspective of poverty might prompt consideration of the impact that being poor has on a child's access to and performance of daily occupations, the factors that restrict or disrupt their choice of occupations, or how their circumstances shape their patterns of occupation (i.e., daily roles, habits, routines, rituals, lifestyle). Or what is the child's experience of occupational engagement whilst growing up in poverty? Evidence from an occupational perspective can help frame the issue of child poverty as an occupational injustice or may provide evidence for the premise that children in these circumstances experience occupational deprivation.
Child poverty in Aotearoa New Zealand
More than 20 years ago the New Zealand government signed the Convention on the Rights of Children (United Nations, 1989) and in so doing made a legal commitment to protect the rights of children and safeguard their well-being. While most NZ children experience a relatively high standard of health and living (Ministry of Health, 2009) a large proportion have remained in long-term poverty (Craig, Reddington, Wicken, Oben, & Simpson, 2013). In 2012 at least 285,000 children or 27% of all New Zealand children were living in poverty (Child Poverty Action Group [CPAG], 2014). Furthermore, childhood poverty levels have worsened over the last 2-3 decades (Children's Commissioner, 2012) and New Zealand children living in poverty face poor health outcomes in comparison to international trends (D'Souza, Turner, Simmers, Craig, & Dowell, 2012).
For Maori and Pacific Island children, the statistics are worse. While childhood poverty levels were similar for Maori, Pacific Island and European children in 1998, there has been a disproportionate increase in poverty levels since then (Maori Affairs Select Committee, 2013). Twice as many Maori and Pacific Island children now live in poverty compared to children of European ethnicity (Maori Affairs Select Committee, 2013). This inequity results in unequal health outcomes for Maori and Pacific Island children and follows a social gradient (Craig et al., 2013).
Several factors have maintained a relatively high level of childhood poverty in New Zealand. These include the suggestion that the neoliberalist social and economic policies of the last 20 years have led to increased economic and social inequalities in this country (Carroll, Casswell, Huakau, Howden-Chapman, & Perry, 2011; O'Brien & Salonen, 2011). Furthermore, global economic difficulties in the last decade have also contributed to this problem, with the global recession of 2008 resulting in a worsening picture of childhood poverty in affluent, developed nations like New Zealand (Child Poverty Action Group [CPAG], 2014; UNICEF Office of Research, 2014). In the view of some child advocates, however, it is a lack of political or societal will to effectively tackle the problem of child poverty that continues to keep children in states of long-term poverty (Bruce, 2014; UNICEF NZ, 2013).
The health outcomes for children living in poverty in Aotearoa New Zealand
Living in poverty adversely effects the physical, mental and emotional well-being of NZ children. Evidence shows that children living in the lowest socioeconomic group are 1.4 times more likely to die during childhood, three times more likely to be sick, more likely to have poor oral hygiene, and later in life are more likely to suffer heart disease, poor educational and employment outcomes, drug addiction, and mental health problems when compared to the rest of the population (Craig et al., 2013). Factors that contribute to these poor outcomes include that while growing up these same children are:
* less likely to eat fresh fruit and vegetables and have a healthy diet,
* less physically active and spend more time in sedentary activities,
* spend less time in free play as young children,
* experience restrictions in their access to sports and recreation as young children and adolescents,
* more likely to be exposed to household rationing choices such as going without new clothing or footwear, sharing a bed, and postponing medical visits
* more likely to live in damp and cold houses placing them at higher risk of respiratory illnesses
* more likely to live in rented housing and to shift more frequently, disrupting schooling and socialization
* at higher risk of maltreatment and family violence
* more likely to experience social exclusion and isolation (Child Poverty Action Group [CPAG], 2014; Craig et al., 2013; Egan-Birtan, 2010; Maddison, Dale, Marsh, LeBlanc, & Oliver, 2014; Ministry of Health, 2009; Q&A Research, 2014).
From an occupational perspective, it would appear that poverty and deprivation restricts the access to and choices of occupation for these children. As a result, their ability to engage in a full and balanced range of occupations that supports growth and development and enriches their lives is being compromised. This is essentially a form of occupational injustice and occupational deprivation. Occupational therapists are well placed to advocate for action that supports healthy community environments and promotes equal access to full engagement in meaningful occupations and healthy activities. Whilst there are likely to be examples of occupational therapy being utilized to address the issue of child poverty in NZ (i.e., as part of organizations or in multidisciplinary teams) (PPTA, 2013), evidence of this has not been published.
Solutions to childhood poverty and the new public health approach
The Ottawa Charter for Health Promotion, originally published in 1986, introduced the notion that health is created within the settings of daily life where people are born, live, work, and play (Marmot et al., 2012). One of the key strategies promoted by the charter is to focus health promotion at a population level rather than focusing on the quality of and access to health services for individuals and communities with health conditions or identified health risks. An example of this is the Healthy Cities Project (Kickbusch, 2003), which recognizes that cities play a vital role in the health of their residents. Work undertaken to achieve project goals are often outside of the health sector, such as improving education, social services, housing, transportation and the physical environment (Lipp, Winters, & de Leeuw, 2013).
The premises of the Ottawa Charter have carried through to the new public health approach, which sees social determinants of health as the key factors influencing health. From this perspective, health is viewed as a life promoting resource, but the focus is shifted from disease prevention to building people's capacity for health (Kickbusch, 2003). The aim is to address health inequity at all levels of society through improving the social determinants of health. The social production of health inequities model, which was developed by the World Health Organization (WHO), provides a schema explaining how socioeconomic factors create and maintain health inequities (Irwin, Solar, & Vega, 2008). In this model, intermediary determinants such as material conditions, and biological and psychosocial factors, interact with structural determinants such as socioeconomic position, occupation, gender, or race to produce health inequities (Irwin et al., 2008). (Figure 1).
In terms of community-based health promotion, programmes need to address the wider socio-political context, focus on both individual and community needs, and combine work with high-risk groups and population-wide strategies (Merzel & D'Afflitti, 2003). Increasing the use of transdisciplinary communication, involving collaboration amongst all agents in a community, is viewed as an effective strategy when addressing public health issues (Wallerstein, Yen, & Syme, 2011). Another effective approach is community-based participatory research (CBPR) which is based on a community empowerment model and uses evidence-based theories, community participation and interventions that are embedded within the local culture and systems (Wallerstein et al., 2011).
An example of a successful community-based programme aimed at addressing child poverty is the UK based non-governmental organisation (NGO) Barnardos, which developed a successful Anti-Poverty Strategy. This focused on reducing child poverty within affected neighbourhoods using principles such as participation by those living in the neighbourhood experiencing poverty, partnership and collaboration by all agencies in the community or region, use of multidimensional approaches to address all known issues creating the poverty, and the use of child-focused interventions (Hughes & Traynor, 2000). Examples of how this was achieved include increased leisure facilities in the community, providing greater access to health and child safety resources, and work with the local council and businesses to improve employment outcomes (Hughes & Traynor, 2000).
Solutions to childhood poverty in Aotearoa New Zealand
The UNICEF NZ report Kids Missing Out (2013) states that ensuring the protection of children's rights will help to improve the wellbeing of all children in New Zealand, but especially vulnerable children such as those living in poverty. The report by the Expert Advisory Group on child poverty Solutions to Child Poverty in New Zealand: Evidence for Action similarly asserts that child poverty can be reduced, but requires a multi-pronged approach that addresses the causes and consequences of child poverty (Children's Commissioner, 2012).
Proposed solutions to child poverty in New Zealand include ensuring children's rights are central to policy making, implementing a comprehensive plan to reduce childhood poverty, addressing the income gap in society, and ensuring a universal health plan and pathway for all children. Also vital is funding of programmes that ensure all children live in healthy and affordable homes, the availability of free food in all schools, and the provision of funding for youth friendly health and social services (Child Poverty Action Group [CPAG], 2014). A further suggestion that arose from consultation with children was to ensure free and safe access to recreational and leisure activities, cultural activities, playgrounds, parks, and public spaces, but especially for children living in disadvantaged neighbourhoods (Children's Commissioner, 2012). These recommendations would ensure that there are equitable opportunities for NZ children to engage in a wide and balanced range of occupations that support their health and well-being.
There are a range of grassroots agencies in Aotearoa New Zealand engaged in addressing social justice issues such as child poverty. Examples include: the work of the New Zealand Council of Christian Social Services and other faith based-communities (NZCCSS, n.d.). The KidsCan charity that supports disadvantaged children to receive essential goods such as food and clothes (KidsCan, n.d.), and the In2it team that works with children, families, and their communities who live in hardship to build stronger connections and relationships through play and a Maori kaupapa or philosophy (E Tu Whanau, n.d.). However, despite the work of these agencies, child poverty and its effects remain prevalent in this country. Based on research, it is clear that strategies that focus on resolving the social and structural determinants of childhood poverty are required (World Health Organization, 2008).
An occupational perspective of public health and the role of occupational therapy in addressing childhood poverty
Public health: The occupational perspective
Over the last two decades occupational therapists have strenuously argued the need for public health to recognise that occupation is itself a fundamental determinant of health (Scaffa, 2014; Wilcock & Hocking, 2015; World Federation of Ocupational Therapists, 2014) and as such can either facilitate or hinder health and well-being (Kiepek & Magalhaes, 2011). Amongst occupational therapists, health promotion and public health are increasingly recognised to be an important and emerging role for the profession (Reitz & Scaffa, 2013; Tucker, Vanderloo, Irwin, Mandich, & Bossers, 2014). Impetus for expanding into public health rests on the Ottawa Charter directive that health is much more than healthcare services; rather, the hallmark of a just society is one that creates equitable social conditions that enable all people to participate in meaningful occupations and can actively engage in society (Hocking, 2013). However, occupational therapists do not yet feature prominently and opportunities to contribute to health promotion and public health are being missed (Hildenbrand & Lamb, 2013).
Wilcock and Townsend (2014) were amongst the early leaders in developing the notion of occupation as a determinant of health and the role of occupational therapy in public health. Since then the profession has been encouraged to move beyond a focus on an individual level of disease and disability and its impact on occupation, to a greater awareness of the impact of social determinants, social inequity and global forces on occupation and health (Hildenbrand & Lamb, 2013; World Federation of Ocupational Therapists, 2014). Hocking (2013) encouraged the profession to look beyond therapy with individuals to work with communities and all levels of society. However, a key issue for the profession as it develops its role in public health is the need for conceptual clarity regarding the role of occupational therapy in this field (Tucker et al., 2014).
Occupation and the impact of socio-political factors
There is a need for greater understanding about the association between occupation, health, and socioeconomic factors. Hocking (2013) highlighted the gap in the literature concerning how people's occupations are affected by social issues such as poverty. For instance, a balanced pattern of occupations in one's life has been shown to be health enhancing (Reitz & Scaffa, 2013). However, there is a paucity of evidence to show how living in poverty might impact on a person's occupational balance or patterns of occupation (e.g., a lack of resources limiting occupational choices), or how one might achieve health promoting occupational balance in the context of long-term socio-economic deprivation (Matuska, 2012; Townsend & Wilcock, 2004; Wilcock et al., 1997). For example, The New Zealand activity report card for children and youth (Maddison et al., 2014) identifies that NZ children living in poverty are more likely to spend time in passive activities such as watching TV, are less likely to spend time in free play, and face restrictions in access to sports and recreational activity, with consequent negative impacts on their health such as higher rates of obesity. Improved access to safe play and physical recreations in their neighbourhoods or a wider range of suitable activity and resources to support healthy occupational choices may be health enhancing for this group of children.
Whilst there have been a number of studies examining occupational patterns for specific groups of people (Blakeney & Marshall, 2009; Holthe, Thorsen, & Josephsson, 2007; Stein, Foran, & Cermak, 2011) and efforts to further define the term (Bendixen et al., 2006), there is dearth of studies exploring the issue of occupational patterns for those experiencing poverty. However, some insight into this topic is provided by a study of how the socio-political context and local experiences of adolescents growing up in a marginalized community in South Africa affected their occupational patterns and choices, and consequently their participation in their community and their health and well-being (Galvaan, 2012). Further research that explores the effect of poverty or other social conditions on people's patterns of occupation is important if we are to contribute to the development of effective solutions.
Occupational therapy's role in public health and health promotion
In keeping with the social determinants of health model, occupational therapy's role in public health needs to consider the wider socio-political factors that effect occupation in order to achieve positive outcomes for communities and the public. Tucker et al. (2014) advised that addressing population health challenges involves the use of health promotion concepts linked with the "determinants of occupational participation and occupational justice" (p. 188). Similarly, Galvaan (2012) asserted that when working with marginalized groups, occupational therapists will need to better understand how socio-political determinants effect occupational choices made by individuals or members of these communities.
The role of occupational therapy in public health also includes identification of the issues that are impeding occupational engagement for vulnerable groups in society and work towards addressing these issues. Reitz and Scaffa (2013) suggested that health promotion involves three important strategies, namely promoting healthy lifestyles, highlighting occupations as an fundamental element of health promotion, and delivering interventions for populations as well as for individuals. As with the profession's work with individuals, the goal to promote health and well-being at a community level by enabling engagement in occupations that enhance meaning, purpose and productivity demands a holistic approach that addresses the wider environmental issues (Tucker et al., 2014).
Using a transdisciplinary approach to work closely with the communities involved, and with other professionals, is seen as an effective way for occupational therapists to work for public health. For instance, Barros, Ghirardi, Lopes, and Galheigo (2005) discussed that when working as social occupational therapists there needs to be dialogue between various sectors of society and between various disciplines. Building inter-professional partnerships with those in the field of public health, along with engaging with policy making that shapes public health, can enhance the role of occupational therapy in the public health field (Hildenbrand & Lamb, 2013; Tucker et al., 2014).
Approaches such as participatory justice, participatory action research, and social justice are a good fit with occupational therapy values and are all positive mechanisms for change in the lives of marginalized individuals and communities. The participatory justice approach has a commitment to working in partnership with the community, being socially inclusive, and ensuring occupational outcomes (Townsend & Whiteford, 2005). Participatory action research addresses issues of inequity and inclusion through collaborative means that involve both action and research (Cockburn & Trentham, 2002). Social justice based occupational therapy calls for action to create inclusive environments, listen to the needs of the community, encourage collective action, and utilise group activities that develop identity and belonging (Galheigo, 2005).
Examples of occupational therapy's role in addressing child poverty
Despite the limited number of published examples of occupational therapy's role in providing solutions to child poverty, those that do exist provide evidence of what the profession can achieve and highlight areas for future research. Researchers might focus on developing the pool of evidence for occupational therapy's role in public health, or in shedding light on the ways in which socioeconomic factors impact on occupation.
One example of a social justice based approach includes improving the lives of street children, who live in marginalized and unjust situations (Kronenberg, 2005). This work involved occupational therapy interventions using a collaborative participant based research approach, whilst maintaining an awareness of the socio-political nature of the predicament that these children face every day. The outcome of this exploratory research was the assertion that occupational therapists can work collaboratively with street children and organisations to help these children to live an improved life through engagement in occupations that are relevant and meaningful to them (Kronenberg, 2005). Another example involving low-income urban youths demonstrated positive results through the use of groups in an after school setting, that focused on occupational engagement, group processes, and social and emotional learning (Bazyk & Bazyk, 2009). This study used a phenomenological research design and the authors suggested there is a role for occupational therapists in promoting occupational enrichment for groups of children facing occupational deprivation (Bazyk & Bazyk, 2009).
A further example identified several ways in which occupational therapists can work with children living in impoverished communities in order to reduce health disparities such as obesity (Cahill & Suarez-Balcazar, 2009). These interventions focused on promoting a healthy lifestyle and developing children's motivation to change their activity and eating habits. This community work used a system level change process, drew on occupation based practice models, and was child centred. Results from this published work showed how occupational therapy interventions resulted in improved knowledge of healthy foods, better food choices, and increased participation in healthy and productive occupations such as gardening and farming (Cahill & Suarez-Balcazar, 2009). Finally, Paul-Ward (2009) used a participatory research design to highlight the views of adolescents in foster care concerning the barriers to independently transitioning to life as young adults in their community. Paul-Ward (2009) argued that assisting marginalized groups such as adolescents in foster care requires a social and occupational justice approach. Such an approach could best be achieved by providing transition facilities with the opportunity to learn new life skills (e.g. cooking or other domestic living skills), providing support to gain employment, addressing the needs of the adolescents from their perspective, and reducing any systemic barriers (e.g. improved communication between agencies) (Paul-Ward, 2009).
While this article attempts to cover the breadth of literature on the topic of child poverty, the review is limited to more recent publications, those most pertinent to the Aotearoa New Zealand context and to an occupational perspective. Furthermore, while the literature review was extensive and the search strategies identified, a systematic review on the topic was not completed and may have provided added rigour to the review process.
Occupational therapy has a long history of working to improve the lives of people through a belief in the fundamental right of a person to engage in meaningful occupation. However, for some time now, the profession has been more focused on treating individuals who are affected by disease, injury and disability. More recently there has been a growing level of support, led by some in the profession, to engage more fully in issues of public health. But the profession is faced with the need to promote its role in this area and grow the body of evidence to support this work. If the profession wants to effectively contribute to addressing important public health issues such as child poverty, then it needs to better understand the links between social factors and their impact on occupation. The profession also needs to determine the best approach for occupational therapists to use when working with communities and how to most effectively engage with other sectors of the community to promote equitable access to occupation. Combining a transdisciplinary communication strategy, a community based participatory approach and an occupational perspective may be an effective way to tackle the social and occupational determinants of health that lead to occupational inequities such as those faced by children who live in poverty.
Occupational therapy, with its holistic, human rights, and occupational approach to public health and health promotion, fits well with the social determinants health model. Although there is a paucity of published evidence to support the profession's role in addressing social justice issues such as children living in poverty, the evidence is emerging. More broadly, such evidence about occupational therapy's potential role in public health and social justice can help shape our understanding of where and how the profession may be most useful in this respect. Research that further explores the effect of social conditions such as poverty on people's patterns of occupation can help to shed light on this matter. This can contribute to understanding the ways in which occupational therapy can positively change the lives of children and adults who face poverty.
1. Poverty negatively impacts children's occupations, leading to occupational deprivation, and is occupationally unjust.
2. Published work by occupational therapists related to childhood poverty is lacking.
3. Conceptual clarity about occupational therapy's contribution to this public health issue and research about how social factors such as poverty effect children's occupations is required.
Attree, P. (2006). The social costs of child poverty: A systematic review of the qualitative evidence. Children & Society, 20(1), 54-66. doi:10.1002/CHI.854
Baker, M. G., McDonald, A., Zhang, J., & Howden-Chapman, P. (2013). Infectious diseases attributable to household crowding in New Zealand: A systematic review and burden of disease estimate. Retrieved from Healthy Housing He Kainga Oranga website: http://www.healthyhousing.org.nz/wp-content/uploads/2010/01/HH-Crowding-ID-Burden-25-May-2013.pdf
Barros, D. D., Ghirardi, M. I. G., Lopes, R. E., & Galheigo, M. S. (2005). Social occupational therapy. In F. Kronenberg, S. S. Algado, & N. Pollard (Eds.), Occupational therapy without borders: Learning from the spirit of survivors (pp. 140-151). Edinburgh, Scotland: Elsevier/Churchill Livingstone.
Bazyk, S., & Bazyk, J. (2009). Meaning of occupation-based groups for low-income urban youths attending after-schoo care. American Journal of Occupational Therapy, 63(1), 69-80. doi:10.5014/ajot.63.1.69
Bendixen, H. J., Kroksmark, U., Magnus, E., Jakobsen, K., Alsaker, S., & Nordell, K. (2006). Occupational pattern: A renewed definition of the concept. Journal of Occupational Science, 13(1), 3-10. doi:10.1080/14427591.2006.9686565
Blakeney, A. B., & Marshall, A. (2009). Water quality, health, and human occupations. American Journal of Occupational Therapy, 63(1), 46-57. doi:10.5014/ajot.63.1.46
Brownlee, K. (2013). A human right against socia deprivation. The Philosophical Quarterly, 63(251), 199-222. doi:10.1111/1467-9213.12018
Bruce, B. (2014). Some inconvenient truths about work. Retrieved from http://bryanbruce.co.nz/feature/child-poverty/some-incovenient-truths-about-work
Cahill, S. M., & Suarez-Balcazar, Y. (2009). Promoting children's nutrition and fitness in the urban context. American Journal of Occupational Therapy, 63(1), 113-116. doi:10.5014/ajot.63.1.113
Carroll, P., Casswell, S., Huakau, J., Howden-Chapman, P., & Perry, P. (2011). The widening gap: Perceptions of poverty and income inequalities and implications for health and social outcomes. Social Policy Journal of New Zealand, 37, 111-122. Retrieved from http://www.msd.govt.nz/
Child Poverty Action Group [CPAG]. (2014). Our children, our choice: Priorities for policy. Retrieved from Child Poverty Action Group website: http://www.cpag.org.nz/assets/Publications/1-0 Our Children Our Choice COMPLETE.pdf
Children's Commissioner. (2012). Solutions to child poverty in New Zealand: Evidence for action. Retrieved from http://www.occ.org.nz/assets/Uploads/EAG/Final-report/Final-report-Solutions-to-child-poverty-evidence-for-action.pdf
Cockburn, L., & Trentham, B. (2002). Participatory action research: Integrating community occupational therapy practice and research. Canadian Journal of Occupational Therapy, 69(1), 20-30. doi:10.1177/000841740206900102
Craig, E., Reddington, A., Wicken, A., Oben, G., & Simpson, J. (2013). Child poverty monitor 2013 technical report (updated 2014). Retrieved from Child Poverty website: http://www.nzchildren.co.nz/document_downloads/2013 Child Poverty Monitor Technical Report MASTER.pdf
D'Souza, A. J., Turner, N., Simmers, D., Craig, E., & Dowell, T. (2012). Every child to thrive, belong and achieve? Time to reflect and act in New Zealand. The New Zealand Medical Journal (Online), 125(1352), 71-80. https://www.nzma.org.nz/journal
Dorling, D. (2013). Unequal health: The scandal of our times. Retrieved from http://www.eblib.com/
E Tu Whanau. (n.d.). In2it team connect families and communities through play. Retrieved December 4th, 2014, from http://nz.etuwhanau.org/articles%2BIndex/In2it+team+connect+families+and+communities+through+play.
Egan-Birtan, M. (2010). This is how I see it': Children, young people and young adults' views and experiences of poverty. Retrieved from http://www.occ.org.nz/assets/Uploads/Reports/Poverty/This-is-how-I-see-it.pdf
Galheigo, S. M. (2005). Occupational therapy and the social field: Clarifying concepts and ideas. In F. Kronenberg, S. S. Algado, & N. Pollard (Eds.), Occupational therapy without borders: Learning from the spirit of survivors (pp. 87-98). Edinburgh, Scotland: Elsevier/Churchill Livingstone.
Galvaan, R. (2012). Occupational choice: The significance of socio-economic and political factors. In G. E. Whiteford & C. Hocking (Eds.), Occupational science: Society, inclusion, participation (pp. 152-162). Oxford, UK: Wiley-Blackwell.
Gunasekara, F. I., Carter, K. N., Crampton, P., & Blakely, T. (2013). Income and individual deprivation as predictors of health over time. International Journal of Public Health, 58(4), 501-511. doi:10.1007/s00038-013-0450-9
Hildenbrand, W. C., & Lamb, A. J. (2013). Occupational therapy in prevention and wellness: Retaining relevance in a new health care world. The American Journal of Occupational Therapy, 67(3), 266-271. doi:10.5014/ajot.2013.673001
Hocking, C. (2013). Occupation for public health. New Zealand Journal of Occupational Therapy, 60(1), 33-37. Retrieved from http://www.nzaot.com/publications/journal/index.php
Holthe, T., Thorsen, K., & Josephsson, S. (2007). Occupational patterns of people with dementia in residential care: An ethnographic study. Scandinavian Journal of Occupational Therapy, 14(2), 96-107 doi:10.1080/11038120600963796
Hughes, M., & Traynor, T. (2000). Reconciling process and outcome in evaluating community initiatives. Evaluation, 6(1), 37-49. doi:10.1177/13563890022209109
Irwin, A., Solar, O., & Vega, J. (2008). Social determinants of health: The United Nations Commission of. In H. K. Heggenhougen (Ed.), International encyclopedia of public health (pp. 64-69). doi:10.1016/B978-012373960-5.00673-0
Kawachi, I., Takao, S., & Subramanian, S. V. (2013). Introduction. In I. Kawachi, S. Takao, & S. V. Subramanian (Eds.), Global perspectives on social capital and health (pp. 1-21). doi:10.1007/978-1-4614-7464-7_1
Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93(3), 383-388. doi:10.2105/AJPH.93.3.383
KidsCan. (n.d.). KidsCan: Supporting disadvantaged Kiwi kids. Retrieved December 7th, 2014, from http://www.kidscan.org.nz/.
Kiepek, N., & Magalhaes, L. (2011). Addictions and impulse-control disorders as occupation: A selected literature review and synthesis. Journal of Occupational Science, 18(3), 254-276. doi:10.1080/14427591.2011.581628
Kim, D., Subramanian, S. V., Gortmaker, S. L., & Kawachi, I. (2006). US state- and county-level social capital in relation to obesity and physical inactivity: A multilevel, multivariable analysis. Social Science & Medicine, 63(4), 1045-1059. doi:10.1016/j.socscimed.2006.02.017
Kronenberg, F. (2005). Occupational therapy with street children. In F. Kronenberg, S. S. Algado, & N. Pollard (Eds.), Occupational therapy without borders: Learning from the spirit of survivors (pp. 261-276). Edinburgh, Scotland: Elsevier/Churchill Livingstone.
Lipp, A., Winters, T., & de Leeuw, E. (2013). Evaluation of partnership working in cities in phase IV of the WHO Healthy Cities Network. Journal of Urban Health, 90(1), 37-51. doi:10.1007/s11524-011-9647-5
Lysack, C. L., & Adamo, D. E. (2014). Social, economic, and political factors that influence occupational performance. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard & Spackman's occupational therapy (12th ed., pp. 188-201). Philadelphia, PA: Lippincott Williams & Wilkins.
Maddison, R., Dale, L. P., Marsh, S., LeBlanc, A., & Oliver, M. (2014). The New Zealand physical activity report card for children and youth. University of Auckland. Retrieved from: http://nihi.auckland.ac.nz/sites/nihi.auckland.ac.nz/flles/NZ PA report card_Long version PDF.pdf.
Maori Affairs Select Committee. (2013). Inquiry into the determinants of wellbeing for tamariki Maori. Retrieved from New Zealand parliament website: http://www.parliament.nz/en-nz/pb/sc/documents/reports/50DBSCH_SCR6050_1/inquiry-into-the-determinants-of-wellbeing-for-tamariki
Marmot, M., Allen, J., Bell, R., Bloomer, E., & Goldblatt, P. (2012). WHO European review of social determinants of health and the health divide. The Lancet, 380(9846), 1011-1029. doi:10.1016/S0140-6736(12)61228-8
Marmot, M., & Bell, R. (2012). Fair society, healthy lives. Public Health, 126, Supplement 1 (0), S4-S10. doi:10.1016/j.puhe.2012.05.014
Marmot, M., & Bell, R. (2013). Socioeconomically disadvantaged people (2nd ed.). Oxford, UK: Oxford University Press.
Marmot, M., Friel, S., Bell, R., Houweling, T. A. J., & Taylor, S. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. The Lancet, 372(9650), 1661-1669. doi:10.1016/S0140-6736(08)61690-6
Matuska, K. (2012). Validity evidence of a model and measure of life balance. Occupational Therapy Journal of Research, 32(1), 229-237. doi:10.3928/15394492-20110610-02
Merzel, C., & D'Afflitti, J. (2003). Reconsidering community-based health promotion: Promise, performance, and potential. American Journal of Public Health, 93(4), 557-574. doi:10.2105/AJPH.93.4.557
Ministry of Health. (2009). A focus on the health of Maori and Pacific children: Key findings of the 2006/07 New Zealand health survey. Retrieved from http://www.health.govt.nz/system/files/documents/publications/focus-on-health-maori-pacific-children.pdf
NZCCSS. (n.d.). Working towards a just and compasionate society. Retrieved December 4th, 2014, from http://www.nzccss.org.nz/site/home.php.
O'Brien, M., & Salonen, T. (2011). Child poverty and child rights meet active citizenship: A New Zealand and Sweden case study. Childhood, 18(2), 211-226. doi:10.1177/0907568210383915
Paul-Ward, A. (2009). Social and occupational justice barriers in the transition from foster care to independent adulthood. American Journal of Occupational Therapy, 63(1), 81-88. doi:10.5014/ajot.63.1.81
PPTA. (2013). Equipping schools to fight poverty: A community hub approach. Retrieved from http://www.ppta.org.nz/resources/media/2797-media-school-hubs
Q&A Research. (2014). Sport and Recreation and the Links with Socio-economic Background. New Zealand Young People's Survey Series. Wellington: Sport New Zealand. Retrieved from Sport New Zealand website: http://www.srknowledge.org.nz/wp-content/uploads/2014/09/YPS-Socio-Economic-FINAL-2-Oct-2014.pdf.
Reitz, S. M, & Scaffa, M. E. (2013). Occupational therapy in the promotion of health and well-being. The American Journal of Occupational Therapy, 67(6), S47-S59. doi:10.5014/ajot.2013.67S47
Rosenbaum, S., & Johnson, K. A. (2013). Children. In B. S. Levy & V. W. Sidel (Eds.), Social injustice and public health (2nd ed., pp. 88-105). Oxford, UK: Oxford University Press.
Scaffa, M. E. (2014). Occupational therapy interventions for organizations, communities, and populations. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard & Spackman's occupational therapy (12th ed., pp. 342-352). Philadelphia, PA: Lippincott Williams & Wilkins.
Stein, L. I., Foran, A. C., & Cermak, S. (2011). Occupationa patterns of parents of children with autism spectrum disorder: Revisiting Matuska and Christiansen's model of lifestyle balance. Journal of Occupational Science, 18(2), 115-130. doi:10.1080/14427591.2011.575762
Te One, S., Blaikie, R., Egan-Bitran, M., & Henley, Z. (2014). You can ask me if you really want to know what I think. Educational Philosophy and Theory, 46(9), 1052-1068. doi:10. 1080/00131857.2014.931008
The World Bank. (n.d.). Poverty: Listen to the voices. Retrieved from http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/0,,contentMDK:20612465~menuPK:336998~pagePK:148956~piPK:216618~theSitePK:336992~is CURL:Y,00.html
Townsend, E., & Whiteford, G. (2005). A participatory occupational justice framework: Population-based processes of practice. In F. Kronenberg, S. S. Algado, & N. Pollard (Eds.), Occupational therapy without borders: Learning from the spirit of survivors (pp. 110-126). Edinburgh, Scotland: Elsevier/Churchill Livingstone.
Townsend, E., & Wilcock, A. A. (2004). Occupational justice and client-centred practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71 (2), 75-87. doi:10.1177/000841740407100203
Tucker, P., Vanderloo, L. M., Irwin, J. D., Mandich, A. D., & Bossers, A. M. (2014). Exploring the nexus between health promotion and occupational therapy: Synergies and similarities. Canadian Journal of Occupational Therapy, 81(3), 183-193. doi:10.1177/0008417414533300
Turrell, G., Haynes, M., Wilson, L., & Giles-Corti, B. (2013). Can the built environment reduce health inequalities? A study of neighbourhood socioeconomic disadvantage and walking for transport. Health & Place, 19, 89-98. doi:10.1016/j. healthplace.2012.10.008
UNICEF NZ. (2013). Kids mising out: It's time to make progress on children's rights. A summary of the first twenty years of the UN Convention on the rights of the child in Aotearoa New Zealand. Retrieved from http://www.unicef.org.nz/store/doc/KidsMissingOutA4DocumentLR-FF.pdf
UNICEF Office of Research. (2014). Children of the recession: The impact of the economic crisis on child well-being in rich countries (Innocenti Report Card 12). Retrieved from http://www.unicef-irc.org/publications/pdf/rc12-eng-web.pdf
United Nations. (1948). The Universal Declaration of Human Rights. Retrieved from http://www.un.org/en/documents/udhr/
United Nations. (1989). Convention on the rights of the child. Retrieved from http://www.un-documents.net/crc.htm
Wadsworth, M., & Butterworth, S. (2005). Early life. In M. Marmot & R. G. Wilkinson (Eds.), Social determinants of health. Oxford, UK: Oxford University Press.
Wallerstein, N. B., Yen, I. H., & Syme, S. L. (2011). Integration of social epidemiology and community-engaged interventions to improve health equity. American Journal of Public Health, 101(5), 822-830. doi:10.2105/AJPH.2008.140988
Whiteford, G. (2000). Occupational deprivation: Global challenge in the new millenium. British Journal of Occupational Therapy, 63(5), 200-204. Retrieved from http://www.sagepub.com/journals/Journal202308
Wilcock, A. A., Chelin, M., Hall, M., Hamley, N., Morrison, B., Scrivener, L., & Treen, K. (1997). The relationship between occupational balance and health: A pilot study. Occupational Therapy International, 4(1), 17-30. doi:10.1002/oti.45
Wilcock, A. A., & Hocking, C. (2015). An occupational perspective of health (3rd ed.). Thorofare, NJ: Slack.
Wilcock, A. A., & Townsend, E. A. (2014). Occupational justice. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard & Spackman's occupational therapy (12th ed., pp. 541-552). Philadelphia, PA: Lippincott Williams & Wilkins.
World Federation of Ocupational Therapists. (2014). Position statement. Global health: Informing occupational therapy practice. Retrieved from http://www.wfot.org/ResourceCentre.aspx
World Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Retrieved from http://whqlibdoc.who.int.ezproxy.aut.ac.nz/hq/2008/WHO_IER_CSDH_08.1_eng.pdf
World Health Organization. (2010). Conceptual Framework of the Social Determinants of Health. In A conceptual framework for action on the social determinants of health: Social determinants of health discussion paper 2 (policy and practice). Retrieved from http://apps.who.int/iris/handle/10665/44489
Simon Leadley, BHSc(OT) Master's student Department of Occupational Science and Therapy Auckland University of Technology Auckland New Zealand
Clare Hocking, PhD Professor of Occupational Science and Therapy Auckland University of Technology
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|Title Annotation:||Feature article|
|Author:||Leadley, Simon; Hocking, Clare|
|Publication:||New Zealand Journal of Occupational Therapy|
|Date:||Apr 1, 2017|
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