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Occupation for public health.

Introduction

Occupational therapists' passionate belief is that the things people do in their everyday lives are the foundation of health and well-being. Generations of occupational therapists grounded that belief in humans' biological capacities--the muscles and neurones that give us movement; the mental functions that empower the capacity to think, feel, and communicate. To inform our work, we learned anatomy, physiology, the medical sciences and psychology. Indeed, that knowledge base was 'enshrined' in the Minimum Standards for the Education of Occupational Therapists, first adopted in 1952 (WFOT, 2002). Alongside the 'hard' sciences, we acknowledged the spirituality that enlivens humanity--each individual's capacity for creativity and transformation, the human potential to overcome adversity and reach for our dreams. But knowledge moved on.

An occupational perspective of health

Over the last two decades, there has been much discussion amongst occupational therapists of the paradigm shift in how we understand, explain and practice occupational therapy. We look back at the practice of the 1960s and 1970s, and perceive it to be mechanistic; overly focused on the components of occupational performance and the number and intensity of repetitions needed to improve function. We now understand that we bought into the reductionism that characterizes a biomedical view of health (Kielhofner, 2004), neglecting the original insights of the founders of the profession--that occupation, in itself, is transformative and health-giving when people engage fully in what they are doing.

Spurred on by scholars such as Mary Reilly, who called on the profession to refocus on occupation, the tide is slowly turning. Reilly's work at the University of Southern California inspired the development of the profession's first comprehensive explanation of people's engagement in daily activities; Kielhofner's Model of Human Occupation (Kielhofner & Burke, 1980). Those beginnings opened the door for occupational science, which recognised the urgent need to establish a scholarly knowledge of occupation to inform the profession. Betty Yerxa, Ruth Zemke and Florence Clark were the primary architects of that programme of scholarship, which was primarily aimed at occupational therapists. In Australasia, the idea of occupational science took a broader view of occupation for the health of the population at large. Ann Wilcock, based at the University of South Australia, and Liz Townsend, at Dalhousie University in Canada were particularly influential in New Zealand. Their work, informed by a social perspective of health, alerted us to the negative health consequences of being deprived of access to a health giving range of occupations and to the injustices experienced by marginalised people in all societies.

Inspired by those ideas, an occupational perspective is now embedded in the 2002 revision of the World Federation of Occupational Therapists' Minimum Standards for the Education of Occupational Therapists. The impact of that paradigm shift is still reverberating through the educational programmes, practice and research of the profession. However, while we have been engaged in a radical overhaul of the 'occupational' part of occupational therapy, the ground on which 'therapy' stands is also being challenged by new concepts about the nature and causes of health. I will argue that there is a second paradigm shift occurring outside of the profession that will challenge occupational therapists to pay more heed to the contexts in which health is created.

Shifting concept of health

I will outline three 'seismic' shifts. These are that:

* Health is primarily determined by social factors

* The measure of health is what people do and become, and

* Health is a fundamental human right.

I will go on to consider what it might mean to have an 'occupational perspective of health' in a context where place, politics, the economy, society and culture are recognised to be the key drivers of the health people create in their everyday lives. I will conclude with a vision of occupational therapists as leaders in public health, people with something useful to say about prolonging life and promoting health for all, not just those with a health condition.

Viewing health from the perspective of its social determinants 'shakes up' established understandings of the cause and course of illness. To understand just how radical that perspective is, it is useful to set it against the prevailing biomedical view. The medical model of health came to prominence at a time when the prevalent health concern was deaths from infectious diseases-scarlet fever, typhus, cholera, consumption (tuberculosis), lockjaw (tetanus) (Carter, 1988), along with polio and flu epidemics. Initial breakthroughs were in discovering vaccines and antibiotics. Scientific methods, which involve "analysing and describing a complex phenomenon in terms of its simple or fundamental constituents" (Oxford, 2012), were pivotal in those advances.

Limitation of the medical view

The First and Second World Wars gave impetus to further medical breakthroughs, including enormous advances in rehabilitation from illness and injury. Scientific evidence confirming the link between cardiovascular disease and cancer and lifestyle factors such as diet, exercise and smoking were also significant because that knowledge points the way to managing and reducing the incidence of the prevalent chronic illnesses of our time--cancer, stroke and heart disease. That accumulated medical knowledge is immensely important to preserving and restoring health.

But it is only part of the picture in relation to understanding health. For example, even with all the knowledge gleaned from decades of research, medicine cannot arrest the increase in diseases attributable to unhealthy lifestyles (Katz, Hermalin, & Hess, 1987). In addition, medical knowledge alone cannot predict who will get sick and who will stay healthy. For instance, medical indicators can only explain about 40% of cases of heart disease. The other 60% of heart disease risk is unknown (Venkatapuram, 2011). That 60% is vitally important, because if societies cannot explain who is at greatest risk, they cannot develop effective health policies.

Social determinants of health

Internationally, and in New Zealand, we have all the facts we need to convince us that people's health status follows identifiable trends. We know that as a group, pakeha people in New Zealand enjoy good health and that the average life expectancy is steadily increasing. Pacifica people don't fare so well, lagging behind pakeha in terms of life expectancy and not experiencing the same steady increase in health outcomes that pakeha enjoy. Maori, the original inhabitants of this land, who might expect to be best positioned to enjoy its benefits, fare worst. They have a full 10 years lower life expectancy than pakeha. So ethnicity is clearly an important social determinant of health. We also know that if we stratify the population according to income, each cohort from rich to poor has decreasing health status. More poor people get sick, more of their children get sick, and their survival rates after stroke, cancer and other noncommunicable diseases are much lower. Worse still, even if we correct for income, Maori have poorer health and health outcomes; just being Maori confers a health disadvantage. Housing, education, and quality of work are other, highly influential social determinants of health (Ajwani, Blakely, Robson, Tobias, & Bonne, 2003). I would also venture that historical injustice is pivotal.

To drive the message home: people's "social conditions determine who is actually born and their genetic endowments, how they behave, as well as the surrounding physical and social conditions" (Venkatapuram, 2011, p. 11). Providing healthcare services can go some way to addressing the health outcomes of social conditions, but cannot level the playing field because health and longevity are primarily caused by social determinants. The most important determinants are access to income, education, warm houses, nutritious food, and clean environments, as well as inclusion and closing the gap between the richest people in a society and the poorest. These are all things that societies can change, and all of them affect the things people do and the circumstances in which they do them. Starting to thinking about health and longevity as the outcomes of socially determined factors, rather than germs, injuries, and lifestyle "choices", tells us that occupational therapists need to look beyond providing good quality intervention for individuals who have already acquired a health condition. At least some of us need to look to the societal factors that influence health and ill-health, so that disparities in the incidence and prognosis of health conditions are addressed. We need to bring our knowledge of occupation to solving the problems of educational under-achievement, overcrowding, damp houses, poor nutrition, decreasing levels of physical activity across the whole population, binge drinking and illicit drug use, domestic violence, homelessness, the isolation of many older people, discrimination against immigrants, youth suicide, insecure employment, and the degradation of the environments where people live, work and play.

Health as participation

The second thing that is reorienting our understanding of health is the International Classification of Functioning, published by the World Health Organization in 2001 and endorsed as the international standard to describe and measure health and disability (WHO, 2012a). The ICF model separates health conditions from the impairments attributable to health conditions, limitations in people's ability to engage in activities, and barriers to participation--the things people actually do. It is an interesting exercise to stand back from the model to ask: Where is health?

Illness is readily identifiable. It is there as a named disease or disorder, with its severity measured in terms of impairments to bodily structures and biological processes, and the activity limitations and participation restrictions that are experienced--noting that all of those elements are moderated by personal factors and the physical, social and institutional environment. Is health defined by NOT having a health condition, or not deviating from normal body structure and function? Is health measured by NOT experiencing limitations and restrictions associated with a disease or disorder? Perhaps--but defining things by what they are not risks becoming very convoluted.

One possible response would be to assert that health is equivalent to participation, which implies that we can determine how healthy people are by examining their pattern of occupation. Reinforcing that perspective, occupational therapists might add that health is both a resource that enables people to participate in the necessary, valued and meaningful occupations of their culture and conversely, participation is the means by which health and well-being are created, experienced and restored. From this perspective, one could conclude that 'participation is the measure of health', whilst again acknowledging the influence of personal and environmental factors in supporting or restricting the actual achievement of health.

Cheering as that conclusion might feel to occupational therapists, it is clearly too benign. Equating health with participation does not explain the differential health status of people from different sectors of society. Following Martha Nussbaum (2011), occupational therapists might be wiser to assert that health is the capability "to do and to be" (p. 18). Capabilities, Nussbaum explained, are both internal and external. The talents and abilities people develop by participating in play, sport, education, music and the arts, work and so on are internal. External capabilities are the freedom and opportunities to use those abilities in their social, economic and political environment. That is, health depends on having opportunities to develop capacities, such as the ability to think critically and the skill to communicate one's thoughts, the confidence to use those capacities, and an enabling environment. Even within relatively benevolent societies such as New Zealand, it is easy to find information confirming that indigenous people, poor people, women, people with a disability, immigrants without legal rights and those whose qualifications are not recognised, do not have the same freedoms and opportunities.

Health as a human right

Naming the groups most likely to experience poor health and healthcare outcomes points to the third seismic shift in conceptions of health: that is, framing health as a human rights issue. Let me quote the first couple of sentences in the WHO World Report on Disability (2011b). "Many people with disabilities do not have equal access to health care, education, and employment opportunities, do not receive the disability-related services that they require, and experience exclusion from everyday life activities. [Given that] ... disability is increasingly understood as a human rights concern" (p. xxi).

To leave us in no doubt, a slew of recent United Nations and World Health Organization documents assert the association between human rights and health. Closing the Gap in a Generation (2008) declares that "a society, rich or poor, can be judged by ... how fairly health is distributed across the social spectrum" (p. i). Human Rights, Health and Poverty Reduction Strategies (WHO, 2008) emphasises that "poverty and ill health are deeply intertwined with disempowerment, marginalization and exclusion" (p. 74). The starting point for the 2012 UNESCO Advocacy Brief on Empowering Girls and Women through Physical Education and Sport is the association between poverty and gender inequality. The opening premise of WHO's (2011a) Human Rights and Gender Inequality in Health is that addressing those issues "is not only the right thing to do, ethically and legally, it also leads to better, more sustainable and equitable outcomes in the health sector" (p. 9). In addition, starting this year, WHO has a mandate to devote special attention to protecting and promoting the right to health of the world's indigenous peoples (WHO, 2012b). The main thrust of the message is that generalised health interventions are not sufficient. Changing the health status of the poorest poor, indigenous people and those subject to discrimination requires strategies specifically developed with and for them.

Linkages between health and human rights

In teasing apart the relationship between human rights and health, the WHO (2002) identified three ways in which health and human rights are interlinked. The most obvious is the ill-health arising from human rights violations, such as slavery, torture, or violence against women and children. Another link is that the ways health policies or programmes are implemented might violate human rights of some groups. Examples include fees that make health care unaffordable, discriminatory practices, health service delivery that breaches cultural conventions about privacy, or health information that is withheld, inaccessible, or inappropriately targeted. Conversely, implementation that ensures health services and health information are accessible, affordable, and culturally safe would promote human rights. The third linkage is when a human rights approach is taken to reducing people's vulnerability to ill-health. That means respecting, protecting and fulfilling each person's right to health by addressing the social determinants of poor health. The most important rights in this regard are the right to education, to nutritious food, and to freedom from discrimination that bars access to a health-giving range of occupations. The WHO analysis reveals that health justice is about righting the social conditions that cause people to "suffer preventable impairments or to die prematurely" (Venkatapuram, 2011, p. 5), such that individuals are free to be and do what they want, in the context of social arrangements that nurture, protect, promote and restore their capability to be healthy.

To summarise: occupational therapy has recommitted to occupation as the specialist knowledge it brings to health. And while we weren't watching, health was becoming much more than healthcare services. Rather, it is the hallmark of a just society that creates social conditions that enable people to do and to be "with equal human dignity" (Venkatapuram, 2011, p. 8). So, how can an occupational perspective nurture, protect, promote, and restore the health of the most vulnerable people in New Zealand-Maori, women and children who live in poverty, and others who are discriminated against. To explore that idea, let us consider two frequently discussed health concerns: the obesity crisis and population ageing.

Occupational perspective of health: Obesity

Obesity is a risk factor for all of the chronic non-communicable diseases that threaten to overwhelm health services: cancer, cardiovascular disease, stroke, and diabetes. The incidence of obesity is rapidly increasing. It affects significantly more women than men (Ministry of Social Development, 2010), and is concentrated in the Maori and Pacifica populations and in the most deprived neighbourhoods (MoH, 2011). Obesity is associated with food insecurity and obesogenic environments--places with fewer fresh food outlets and recreational facilities, and lower perceived or actual safety (Jones, Bentham, Foster, Hillsdon, & Panter, 2007). A great number of researchers are addressing the problem of obesity, from different angles: nutritional, physical exercise, gender, age, how intention to be more active translates into behaviour, what sustains people's engagement in physical activities, how neighbourhood design influences activity levels.

What I haven't seen is research conducted with populations that are most at risk of obesity that puts together all the aspects of their everyday lives that influence nutritional intake and energy expenditure: their work, social, celebratory, leisure and spiritual occupations; time use and sleep patterns; types of transport and destinations; and the economic, cultural, geographic, climatic and social influences on the occupational patterns that contribute to obesity. We need to understand all of the antecedents to driving into McDonalds, sending children to school without breakfast, watching TV instead of more active pastimes, eating processed food rather than fresh vegetables. And we need to understand how people's occupational patterns are influenced by things that society can change--the location of supermarkets, urban design, living in poverty, overcrowding.

Research of that kind, designed to identify the enablers, barriers and mechanisms that underlie food choices and activity levels, would expose the array of social conditions that contribute to obesity and how they interact. Such an occupational perspective has the potential to generate new insights, because people's occupations integrate their internal capacities and what they have the freedom to do in their social environment. Until we have that knowledge, I don't believe it will be possible to develop effective public health policies to turn the tide.

Occupational perspective of heath: Population ageing

Population ageing is another demographic change with potential to overstretch healthcare services (Statistics New Zealand, 2008), as more and more people survive into old age. The magnitude of the challenge is revealed in the figures for health expenditure, which documents rapidly increasing costs of disability support services for cohorts over 74 years of age (Bryant, Teasdale, Tobias, Cheung, & McHugh, 2004). To remain healthy, older people need to engage in occupations that are physically taxing, mentally stimulating, and connect them to community. Dementia threatens people's capability to do that. Its prevalence in people aged over 65 increases by 1-2% per year of age to approximately 34% of those aged 90 years and older (Alzheimers New Zealand, 2008).

Dementia is known to undermine people's ability to participate in everyday occupations. However, although their reduced participation is generally attributed to cognitive decline, a recent New Zealand study revealed that it is the stigma they encounter that causes people with dementia to hide their condition and withdraw from society (O'Sullivan, 2011). That response is hardly surprising; media portrayals of dementia position it as a 'living death', characterised by inappropriate behaviour and devoid of meaningful engagement in occupation. Anticipating other people's lack of understanding and condescending attitudes, people diagnosed with dementia hesitate to ask for assistance with practical aspects of familiar tasks, such as selecting items in a shop, withdrawing money from a bank, or keeping score at golf.

Informed by O'Sullivan (2011), two focuses for occupational therapists' knowledge of the health-giving power of occupation become evident. One is that people diagnosed with dementia need a hopeful message of living fully to preserve the highest level of well-being. But justice is not served by telling people subjected to stigmatising attitudes that it is up to them to get on with their lives. Societal attitudes must be challenged and an enabling environment created in order for people to use their capabilities. Imagine a world where shoe shop assistants, bank tellers, and gym coaches could unobtrusively greet, prompt, and allow the time people with dementia need to participate in familiar and unfamiliar tasks. Imagine a world where friends and acquaintances would continue to feel confident with and welcoming of them, even as memories fade, words prove elusive, and decisions are not so quickly reached. What is needed is more than a change of attitude; it is a level of skill in enabling others' occupations that would benefit everyone. Occupational therapists have the knowledge to make that happen.

Conclusion

I have painted a picture of an occupational perspective bringing valuable new insights to two of the many public health issues facing New Zealand: obesity and the well-being of people diagnosed with dementia. Making a real contribution to public health, the art and science of preventing disease and prolonging life, is not just a new area of practice. It demands sharing knowledge of occupation for health at a societal level, making it as familiar as dietary advice--but better tailored to people from the different cultures that make up New Zealand. In particular, I have suggested that addressing the disparities between Maori, Pacifica people, and pakeha, and between rich and poor, is a cornerstone of achieving health for all. It also means extending our thinking from practice with individuals, to practice that influences groups, organisations, communities--the whole of society. Moving in that direction will require leadership, in large and small ways; from influencing government policy to offering to work with people to create an enabling environment. That might be as simple as suggesting that the local play centre preserves some open space for children to run around in or speaking to a hair dresser or gym instructor about interacting with people with cognitive challenges. It also demands research, conducted with and for the groups most at risk from avoidable ill-health and premature death, which brings to light the ways that their social conditions work against health and well-being. Stepping up to the challenge requires the courage born of recognising health injustices and knowing that an occupational perspective is an important part of the answer. It will be an exciting journey that honours the profession's commitment to biculturalism and its early history of social activism. I invite you to join me.

Key points

1. Health is determined by things societies can change

2. The measure of health is what people do

3. Health is a fundamental human right

4. An occupational perspective is central to addressing health injustices, using a public health approach.

Acknowledgement

This paper is Dr Hocking's Inaugural Professorial Address, presented at the Auckland University of Technology on 29 August 2012. To view the presentation, go to http://ondemand.aut.ac.nz/Mediasite/Play/7b72f0cdff4a4a05a5bd8f3f7c1216401d

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Clare Hocking, PhD, Professor of Occupational Science and Therapy

Corresponding author:

Clare Hocking

Department of Occupational Science and Therapy

Faculty of Health and Environmental Sciences

Auckland University of Technology

Auckland

Email: clare.hocking@aut.ac.nz
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Title Annotation:FEATURE ARTICLE
Author:Hocking, Clare
Publication:New Zealand Journal of Occupational Therapy
Geographic Code:8NEWZ
Date:Apr 1, 2013
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